​A risky road to recovery | Phnom Penh Post

A risky road to recovery

Post Weekend

Publication date
24 October 2015 | 07:04 ICT

Reporter : Vandy Muong and Harriet Fitch Little

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Ambulances from Chak Angre clinic sometimes make three border runs in a day.

Travelling overland to Vietnam is often the last hope for those in need of emergency care. But the long journey, and unscrupulous ambulance operators, make the trip a treacherous gamble It’s 7:45am at the year-old Vietnamese-owned Cho Ray Hospital, located on National Road 1, at the far reaches of Chbar Ampov district. An ambulance is parked outside, and a dozen-odd people are milling around the open vehicle, tense and confused. “He’s dead already,” a man is saying down the phone, a sleepy toddler hanging off his arm.  Another disagrees. “They’re just getting him ready to take him Vietnam,” he insists.  Periodically, the smartly groomed Dr Bunthorn emerges from the room where medics are trying to stabilise Ros Virak for transfer. The doctor never removes his facemask, which makes his expression hard to read. Each time, his prognosis is slightly different. “It’s a busy morning,” he repeats apologetically, before disappearing again behind the swinging double doors. Almost every morning at Cho Ray hospital begins with a similar scene. At 8am, doctors and administrative staff meet and discuss which patients, often emergency cases admitted within the past 24 hours, are eligible for transfer to Cho Ray Hospital’s sister facility of the same name in Ho Chi Minh City, where the emergency care facilities are more advanced.

Cho Ray Hospital will only transfer patients to Ho Chi Minh City if doctors believe they will survive the journey. Hong Menea

Their decision has two key questions: can the family pay, and will the patient survive the journey? Cho Ray is one of about a dozen clinics in Phnom Penh that operate cross-border ambulances. Exactly how many ambulances are making the journey is unknown – while Cho Ray transfers patients using a costly “ambulance passport” that must be renewed every four months, many private operators fly under the radar, carrying patients in unmarked vehicles and transferring them into Vietnamese ambulances at the Bavet border crossing in Svay Rieng.  “People have lost belief in the healthcare system in Cambodia,” says Sin Dara, head of human resources at Cho Ray. Ros Virak is a case in point. The 20-year-old man, his parents’ oldest son, was originally admitted to a provincial hospital following a motorbike accident in Kampong Cham two weeks before. Doctors checked him over but could find nothing wrong with him and sent him home. Then Virak started having intense headaches. Shortly after, he lost the ability to speak or move, and his skin and eyes turned yellow. His parents transported him to Cho Ray, where a different diagnosis was presented: sceptic shock, multiple organ damage and cerebral malaria.

Ambulances going to Vietnam must have a ‘passport’. Hong Menea

“We want to take him to Vietnam to have treatment there because they have equipment for brain specialists,” says Yean Darong, Virak’s aunt, speaking quietly. “We’ve done all the preparation for this morning, but now the doctor is asking us if we still want to go.” Virak’s parents crouch in the shade, silently heaving. His mother clutches a bundle of incense sticks, ready to be lit if her son doesn’t survive.   A dangerous ride For Cambodians looking for healthcare abroad, there is a sliding scale of possibilities. For the wealthy, Singapore is first choice, Bangkok second. Patients will be flown either by commercial plane or air ambulance. The clinic manager of a leading international clinic in Phnom Penh, who wished to remain anonymous, said that transfers by road to Vietnam were not on their list of options: “There are a lot of health risks for the patient involved in the delay – it’s the time factor mainly.” Even with the newly inaugurated Tsubasa Bridge removing the need for a jarring ferry crossing, the trip to Ho Chi Minh City still takes a minimum of five hours. But for patients who do decide to make the journey by road, Cho Ray promises perhaps the highest likelihood of success: its ambulances are equipped with oxygen tanks, ventilation equipment, a nurse and a doctor. The ambulance passport allows for the patient to cross the border easily without moving between vehicles.

Ros Virak is wheeled into a waiting ambulance.Pha Lina

Sous Song Veacha, a popular singer who suffered from a brain haemorrhage earlier this month, described the experience as relatively straightforward. “I was concerned on the way to Vietnam, but I didn’t have to worry because I had a doctor to go with me,” he said, speaking out of the window of his Lexus in the hospital car park. Song Veacha paid $600 for the transfer, which he will undertake again in 10 days for a check-up. For those without money or medical know-how, things are different. A few months ago, the story of orphaned teenager Loun Leang Heng spread around Cambodian social media. Leang Heng was poor and living with his grandmother in the provinces when his kidneys began to fail. An uncle took Leang Heng to Calmette Hospital in Phnom Penh, and various friends and acquaintances visited to check up on him. In the end, it was an acquaintance – a monk called Rounh Chhum Vichhouk – who took charge of organising an ambulance for Leang Heng when he saw that his condition was worsening. “I remember it was around 10pm. We took him from a Calmette ambulance to another ambulance. I didn’t focus on which company or clinic or hospital’s ambulance it was because I just wanted to see him off to Vietnam,” he said. The private ambulance was slow, and at the border it took half an hour to transfer him between vehicles. Shortly after arriving in Vietnam, Leang Heng died, and friends raised money to have his body repatriated. When contacted by Post Weekend, none of the boy’s family or friends could name which ambulance provider he travelled with.

Oxygen tanks are essential. Hong Menea

Cho Ray’s Sin Dara said that the story was not uncommon. Often, he said, the patient didn’t even make it as far as the hospital. “The ambulance service isn’t advertised broadly, so some people don’t have information about what kind of service they can get,” he said. “They reject ambulances from public hospitals and they find that some clinics have ambulance services from Phnom Penh to Vietnam, but ultimately the patient dies along the way because there is no oxygen, no medical equipment for intervention if there’s a problem. They don’t have a doctor to analyse the situation.” A lucrative trade Cambodia’s private ambulances have a history of mercenary behaviour, often fighting over injured victims on arriving at the scene of an accident. It’s a rogue trade that the government has been trying to crack down on, with some success.  “Before we took people who had accidents on the street, but recently the government are not allowing private clinics to take them,” said Y Kea, general manager of the small Chak Angre Clinic on National Road 2. “They blamed us when we took them and they didn’t have family or relatives [to pay].” But Chak Angre is still able to provide ambulances for patients looking to go to Vietnam. It’s a lucrative business – Kea says they will sometimes make three border runs in one day, each bringing in between $400 and $700. The price depends on the package: it costs more if you want to travel with a doctor, and if you want to avoid changing ambulances at the Vietnamese border.

Cho Ray Hospital is seen as providing some of the best inter-country transportation on offer.Hong Menea

Rather than transporting people that have already been admitted to the clinic, most of Chak Angre’s Vietnam-bound patients contact them with the sole purpose of making the journey, often transferring from other hospitals to their ambulances.   Kea said that the clinic is diligent in checking the health condition of all patients it transports. However, he does not keep details on file of those who have made the journey. “We never record patients details and we can’t remember their names,” he said. It’s a similar story at Mekong Clinic in BKK1, which advertises “Ambulances to Vietnam” in large letters outside its entrance. If you call Mekong Clinic, it is the ambulance driver not the doctor who picks up the phone. “I am not a specialist or a doctor,” said Oung Sarin, who has been the clinic’s driver since 1997. “When the patient calls me, I need to check with the doctor to see whether they can go [to Vietnam] or not.” Nonetheless, Sarin said he was often the one in charge of making critical calls about patient treatment, including which hospital to send them to, operating the ambulance’s medical equipment and calling ahead to Vietnamese ambulances waiting at the border crossing to explain what to expect. If no one travelling with the patient speaks Vietnamese, Sarin will provide over-the-phone translation as he makes the trip back to Phnom Penh.

ambulance wars Regulating Phnom Penh’s private clinics has been a longstanding headache for the Cambodian authorities, nowhere more so than when it comes to their ambulances. In November 2008, it became illegal for private ambulances to pick up injured patients from the scene of an emergency. The argument for the ban is twofold. Firstly, lax regulation on private ambulances means that the vehicles may be poorly equipped, lacking necessary lifesaving equipment or even a doctor on board. Secondly, private ambulances are seen as avaricious. As Sin Dara, head of human resources at Cho Ray Hospital puts it: “They just compete to pick the patient along the side of the road. If they look poor they refuse to take them.” “Some ambulances don’t even register with the Ministry of Health – they don’t even get a logo to stick on the car,” he said. But the fact that Cambodia’s public ambulances are under-resourced and often slow to arrive on the scene has made it hard to enforce the ruling effectively. Y Kea, general manager of the Chak Angre Clinic, said that picking up injured patients was a question of compassion: “I know they’ve had this policy since we opened the clinic, but we still would sometimes take [emergency cases] because if we saw them and we ignored them, it would have been so bad.” He added that the government and publicly owned hospitals were now working harder to enforce the law, making it difficult for private ambulances to transport patients unless they had received a specific request. “They never allow us to go in,” he said, referring to the publicly owned Calmette Hospital. “If we want to go, we need to fill a lot of forms, and they have their own ambulance as well.”
Having grown up in Vietnam, he is fluent in both Khmer and Vietnamese, but can neither read nor write Khmer. Like Chak Angkre clinic, Sarin said he did not keep the medical records of the patients he transports. Both the Mekong Clinic and Chak Angre are happy to speak on the record about the services they provide – their ambulances are clearly marked and, while sparse, are equipped with basic medical supplies. And, as both clinics are quick to emphasise, they will turn down patients if they feel the risk of travel is too high. But according to Cho Ray’s Sin Dara, around half of cross-border ambulances operate entirely under the radar, often in unmarked vehicles. Inquiries made by Post Weekend into one such clinic bore out his claim. On a visit to Clinic 215, a small practice that looks more like a house than a hospital, the pyjama-clad receptionist told reporters that it had never operated any cross-border services. But when contacted anonymously by phone two days later to inquire about the possibility of a transfer to Vietnam for a relative with a brain haemorrhage, the clinic readily provided a price list for the transfer: $450 if the patient were still conscious, $550 if not.  Cho Ray’s Dara, who was not willing to speak about specific ambulance providers, said the unlawful service was the result of a simple cost-benefit analysis. “If the Ministry of Health finds out your clinic is not registered to run an ambulance service they have a penalty, but they don’t charge a lot so [the clinics] don’t care,” he said. He said that to be eligible for transfer at Cho Ray, you must already be an in-patient at the hospital. “Then if [the illness] is higher than what we can respond to, we will refer them to Ho Chi Minh City,” he said. For the family of Ros Virak, the possibility of treatment has come too late. After three hours, Dr Bunthorn emerges to make his final prognosis. “It is hopeless,” he says. Virak’s heart rate, which dropped around 8:30am, never recovered. The trip for which his landless parents sold their sole asset – a small truck – will not happen. Instead, the ambulance will be used to carry his body back to Kratie. At 11am, the ambulance is driven closer to the door. Virak’s parents raise themselves from the ground. Their son’s body is wheeled out into the waiting vehicle. They follow, lighting the incense they hoped never to burn, so that their son’s ancestors can guide him home. 

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