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Culture crash: Trauma in 1994 Cambodia

      In March 1994 I was searching for work in Phnom Penh, Cambodia, 2 weeks after I had moved there with my husband, who had accepted a teaching position. I was still searching for work. I had visited many nongovernmental organizations such as Medicins sans Frontiers and the American Refugee Committee and had been told over and over that no nursing positions were available, never mind a position for an ED nurse. Given the raw poverty and related health care problems in the struggling nation, I was growing frustrated at the seemingly endless number of pencil-pushing jobs and dearth of nursing jobs. I suppose this experience was valuable for me in a way, because American nurses can usually avoid the useless feeling that accompanies involuntary unemployment.
      It was a Sunday and there was no job searching to be done, so my husband Harry and I became tourists for the day. We walked around our new city. Although Phnom Penh undoubtedly was once beautiful, as some people insisted, much had decayed or been destroyed in the previous 20 years of war. Just one year earlier, in 1993, many refugees from the camps on the Thailand border had come to Phnom Penh, and many were still seeking homes and jobs. Some people seemed to be rebuilding, but many were too poor and too weak to focus on much else besides finding enough food for the day.
      Just after noon, Harry and I walked down Norodom Boulevard, the prettiest street in town. It was a busy 4-lane thoroughfare, one of only 2 major paved streets that ran north-south. Lined with flowering trees and French colonial buildings, it felt very European. I photographed roadside stands at which cigarettes and green milky liquid (that guidebooks recommend you do not imbibe) were sold. Motor scooters called ‘motos’ and ‘cyclos’ (a chair in front for the rider and a bicycle in back) that were for hire passed by. Back home as a trauma nurse, I appreciated safety standards and always encouraged my patients to wear their helmets. However, not many helmets existed in Phnom Penh, because buying a small moto required a few years’ salary, and buying a helmet required a few months’ salary. I was impressed with how Cambodians could transport a family of 5, including a breastfeeding mother-baby combo, on a moto. There seemed to be few stoplights or stop signs and no traffic rules to follow, except to go slow enough to merge. Riding in traffic felt like a continuous game of “chicken.” Driving was usually done on the right, but if traffic was congested, traveling on the left seemed equally acceptable.
      As we walked, people driving by stared at us. Westerners were unusual. They stared at us so long, I feared people would crash.
      We approached a large ornate building with a banner advertising the day’s conference on the new press law. Sport utility vehicles (SUVs) filled the parking lot, which was unusual because almost all traffic then was on 2 wheels, except for some vehicles driven by government officials, the security forces, and those (mostly Westerners) who worked for nongovernmental organizations.
      We passed the entrance to the building as a white SUV began to approach the driveway to the compound, turning left across traffic. The Cambodian turning custom was to drive directly into oncoming traffic, which usually accepted the turning vehicle and merged around it. Smaller vehicles yielded to larger ones—if they could.
      The sound of screeching brakes turned our heads. Bright sparks showered from the pavement. The driver of a moto coming from the other direction had laid his bike down before it slammed into the rear wheel of the SUV, sending 3 people flying through the air.
      I froze for a moment, in denial that the crash had happened. Transforming into trauma nurse mode took a moment. I ran around the SUV to find the 3 teenage boys lying still and unconscious in various twisted and crumpled positions. I approached the moto driver, who was lying with his head rotated 145°, and began a quick assessment. I was frustrated that I could not evaluate all three of them at once. I decided that the moto driver’s ABCs were okay, and then turned him supine to place him in a position for C-spine precautions. As I started a secondary assessment, he shuddered as if he were going to seize. Visions flashed before me of blood draining from his ears and me standing over his dead body. I got a grip on my anxiety when, instead, he opened his eyes. I tried to get him to keep his head still, but it was a vain attempt with my 5 words of Khmer, the Cambodian language.
      Immediately, one of the traffic policemen who stood guard along Norodom Boulevard started drawing chalk outlines around the moto, the bodies of the boys, and the SUV. I wanted to leave the driver so I could assess the ABCs of the other 2 boys who were lying tangled together, their limbs wrapped around each other. I took my hands off the driver’s head to go to the 2 boys, and the driver sat up. I returned to hold him still, then tried to go back to the other two; as if in a bad slapstick comedy, I could not assess the other 2 boys because the driver would not hold still.
      A crowd formed out of nowhere. Two middle-aged Cambodians ran over to the 2 boys lying in their tangled ball of flesh and flipped them like pancakes onto their backs. Then they began squeezing, rubbing, and massaging their chests and abdomens so vigorously I thought they were going to rupture a spleen. I asked Harry to try to stop this medical care. In English he registered an objection for me; they looked at him quizzically for a few seconds, then continued. The maneuver woke up the 2 boys, who began to roll back and forth on the ground and moan. Then the couple ran over to the driver I was tending to, lifted up his shirt and began pushing and squeezing his abdomen and chest. I waved my hand back and forth as the Cambodians do to say no; they looked at me with confusion. Apparently satisfied that the 3 boys were reanimated, they finally stopped.
      I asked Harry to see if he could summon an ambulance. He made the sign of a telephone to the policeman, who nodded with understanding. It seemed like the appropriate personnel would be called to the scene.
      Desperate to communicate, I called out over and over for someone to tell me the word for pain in Khmer as I tried to assess the driver. A teenage Cambodian boy approached and said he knew some English. I explained I was a nurse and knew how to take care of crash victims. He seemed to understand, and I supposed he would tell the 3 boys.
      Suddenly, the crowd decided everyone should be cleared from the road. My objections were not noted, and the driver was picked up from under me as I pointlessly tried to hold C-spine precautions. The boys were set down on the jagged, broken sidewalk. After hounding the reluctant translator to help me assess the patients, I palpated their bodies while he asked if they had any pain. After 15 minutes of struggling with the translator, it appeared as though the victims probably did not have any serious neck, chest, or abdominal injuries. One teenager had a contusion on his occiput and another had a big swelling on his tibia, but it was not deformed, and he walked on it a little. All three of their thin bony bodies were marred with deep road rashes. I flashed back to my hospital in the United States, wishing I had 6 well-controlled hours to observe them before deciding they were okay.
      A few minutes later, I noticed that the white SUV had disappeared into the compound. The motorcycle was rolled to the sidewalk. The driver turned the key to the moto; it did not start. The middle-aged woman from the reanimation team found a container of Tiger Balm in her purse and began spreading it over the road rashes of the boys, grinding the dirt even deeper into their wounds. Like a smelling salt, she wiped some Tiger Balm under their noses. A man in his 30s with more English skills stopped by. I asked him to tell the boys to wash their wounds out with soap and water when they got home, wondering how hard it was to get Tiger Balm out of a road rash. But then I thought, if it is not safe to drink the water here, why should I tell them to wash their wounds in it? What should I tell them? (I should have told them to use water that was boiled and then cooled, but I was still too new at living in the developing world to know that then.) The translator was reluctant to relay the message to clean their wounds because “they won’t listen anyhow, there is no point in it.” I asked him 4 or 5 more times before he finally complied. He helped me translate for a few more minutes, then told me he was leaving. The translator with less English drifted back.
      I decided that they all looked like they were going to survive, and I really did not want to send them to the hospital. On one of my futile job-searching expeditions, I had visited the main hospital in Phnom Penh. No lights or fans were on and no nurses or doctors were to be seen, because I did not go between 8 to 11 AM , their only working hours of the day. The patients sweltered in the tropical heat, tended to only by their families. Some lay on slats of wood, or a “bed,” others on grass mats on the floor. Most were emaciated. A 50-ft long, 10-ft tall pile of trash behind the hospital burned, perhaps to reduce the presence of vermin, though certainly not to improve the respiratory functions of the patients. Flies swarmed ferociously around human waste. No running water was available.
      When I saw the hospital conditions, I figured “do no harm” was not a strong theme there. Florence Nightingale was battling these same conditions 150 years ago in the Crimean War. So I was reluctant to send my patients to the hospital. On the other hand, I knew that radiographs were indicated here. I asked my translator where there was a hospital with x-ray machines, but he did not know.
      The driver got dizzy and sat back down. All three of the boys were pale and sweaty. It was extremely hot, maybe 100°F. I remembered that the guidebook said that intravenous fluids were not always sterile in Cambodia, which made me more reluctant to send them to the hospital. I dispatched Harry to look for a roadside stand selling bottled water. He returned after a lengthy search to report the stands within a few blocks of the crash were only selling some liquid in old soda bottles that he thought was probably gasoline.
      The boy with the tibial problem started to complain of right flank pain. Two minutes later when I questioned him again he denied the pain. I tried to get the translator to tell the boy to watch for hematuria, but he had not yet learned the words “urine” or “pee” in his English classes, and I could not get the point across without acting as if I was urinating myself, which I did not feel like doing.
      After half an hour, it finally became clear to me that no ambulance was coming. I then recalled that I had not heard a single siren since my arrival in Phnom Penh. One of the boys asked about going to the hospital. Despite my reservations, I decided whatever hospital there was here would probably be better than me sending them home or assessing them on the sidewalk for 6 hours. But I did not know how to transport them. Harry and I did not have a car; we traveled either by cyclo or moto. I suggested to the boys that maybe they could take a cyclo to the hospital. The translator looked at me like I was exceptionally rude. I assessed the 3 boys some more and my translator continued to be reluctant.
      The boy with the tibia problem stared at his motorcycle. He said it did not work very well anymore. I told the translator the boy should worry about his body first and his motorcycle later, while I continued to repeat my recommendation that he take a cyclo to the hospital. The translator asked me to bring them to the hospital. I again suggested a cyclo and told him I had no car. Then the translator told me the boy wanted some money to get his motorcycle fixed.
      It finally clicked.
      I said, “Do you think I was the one who was driving the truck?”
      “Oh yes,” he replied, “you were the one who hit them!”
      “You think I hit them? No, I am a nurse, I was walking along the sidewalk and saw the crash and I came to help. Please tell him I am not the one who hit him,” I said.
      The translator spoke 2 words in Khmer, obviously not translating anything. I stressed again he should tell the boy I did not hit him, I have no car. “A white Toyota truck hit you. It is in there!” I said, pointing into the large compound where the SUV had gone.
      Again, he translated almost nothing. He asked once more for some money for the boy to fix his moto.
      I knew it was unacceptable in Cambodia to become loud, but my frustration outweighed my desire to follow the cultural rules and I began to cause a stir. The group surrounding us grew with my voice, which became louder each time I was not translated.
      Having no further role as a nurse, I said good-bye, turned, and abruptly walked away with Harry.
      The group stood silently and watched us go. The 3 boys sat rubbing their injuries and staring at their wounded motorcycle.