Monday, March 7, 2011


By: Maggie Kuhn, MD

Medicine does not exist in a vacuum. It’s a simple enough concept, and statement for that matter. There are probably hundreds of essays written with this premise every year, by college students eager for medical school acceptance. And how we practice medicine is reflective of our priorities: not only as physicians, but as a society and a culture. I know that I understood this at one time, and I know that I even contemplated in the past. But life gets busy: we get up early, we round early, we see patients and put out fires and attend conference all before a 7:30 am start. We go, go, go, we complain that anesthesia is slow, that the nurses are slow, that the patients aren’t compliant, that the other services don’t really care—and before we know it, we’ve been at this five years.

This experience for me, going somewhere completely foreign and seeing medicine in a completely new context, has been one that has required me to slow down. And slowing down, for me, has proven immensely difficult. Kossimak Hospital has an 80 bed orthopedic trauma unit. But things at Kossimak are different now than they were 2 years ago. Two years ago, the 80 beds were filled—so much so that two visiting surgeons contributed over £150,000 to build a new unit. But two years ago the government changed the compensation structure for surgeons and hospitals. For reasons unclear to me, prices for patient care went up and physician compensation went down. Now, the ward is at least half empty—patients cannot afford the $280 surgery fee, or the $30 a day to stay in the hospital. Most of them go to traditional healers or ‘bonesetters’ for their initial care. Otherwise, they go to the less expensive and closer provincial hospitals. This poses two problems. First, their care is not as good: resources are even more limited and physicians are less trained. Secondly, appropriate care is delayed—when the patients finally do present, it is months or years later, and fractures have become nonunions or, worse, malunions, elbows are stiff, joints are contracted, and the patients have lost their jobs.

Despite this, the dedicated surgeons at Kossimak continue to operate as much as they can. Four of the five operating rooms on the campus are dedicated orthopedic rooms, treating almost exclusively trauma patients. The crowdedness of city streets, the prominence of “motos” or scooters, and the lack of traffic laws (or, at least, their enforcement) make for plenty of business. The surgeons at Kossimack, and especially their dedicated chief of staff, Dr. Bunn, have done more SIGN nails than any other institution worldwide: over 1,300. The nail itself allows for long bone fractures, which are by far the most common orthopedic injuries seen in Cambodia, to be treated with intramedullary fixation. In the US, this fixation technique is frequently utilized in order to stabilize fractures internally and to allow patients to ambulate early after surgery. The alternative is the time tested and reliable “traction” technique, whereby patients with lower extremity fractures are maintained in bed, with traction applied to the affected extremity, until they heal—often upwards of 8 weeks.

Conditions in the operating rooms are sparse. There is air conditioning, but no running water in the rooms. Drapes are cloth and, often, rattled with holes that require multiple adjustments to maintain a sterile field. The surgical trays are sparse: one drill, but otherwise without power tools. There is one needle-driver and one knife blade per set, and generally very little uniformity to the trays themselves. All bone reaming and screw placement is done by hand, and all screws have to be hand tapped. Probably the most glaring difference with respect to the operating room setup is the fact that fluoroscopy is notably absent from nearly all procedures. Of all the frustrations I encountered trying to acclimate to a different system of operating and of administering health care, this was likely them frustrating. Lack of fluoroscopy, or intraoperative x-rays, is not uncommon in the developing world. In fact, the SIGN nail was developed expressedly to avoid the need for fluorography in the OR. But Kossimack hospital has two fluoroscopic machines, one in each of 2 operating rooms, which have been donated. Despite having the machines, the surgeons are exceedingly reluctant to use it, as many believe its use will make them impotent.

It is the care before and after surgery, however, that was most disparate from my own experience. If you were to sustain a femur fracture in Cambodia, say from a moto accident, your family would drive you to the hospital—in a car if you had one, but more likely on the back of a moto or a bicycle. If you had insurance, you could stay in the air conditioned rooms, but if not, if you’re like most Cambodians, you would be escorted to a room with 8 beds, a fan and no linens. For $30 a day, you could stay in the hospital and be provided IV drips, medications and dressings for your wounds. Your family would have to pay this daily fee on a daily basis—actually to the physicians themselves. Food and water, of course, are not covered, and families provide these for patients. Similarly, while nursing care is available for dressing changes and medication administration, family members bear the burden of moving patients to and from bed, changing bed pans and getting the patients up on their feet and beginning basic physical therapy. Not food, of course.. If you needed surgery and could afford the $280 surgical cost in addition to the cost of the implant used, your surgery would be scheduled two or three days after your admission. Your chance of contracting a post-operative wound infection would probably approach 10% if you were young and healthy, and your hospital stay would be about 5 to 7 days (or, as many days at you could pay for.) While these costs seem dramatically low, they are relatively high for Cambodian citizens, many of whom make less than $1,000 annually. Surgical orthopedic care is prohibitively expensive, and many patients simply cannot afford to come to the hospital, at least not initially.

The concept of outpatient care, both pre and post-operatively is a relatively new one at Kossimack. The surgeons there, with the help of World Orthopedic Concern, have recently established an outpatient clinic where patients can be seen. The concept, however, has not yet caught on with patients, many of whom have difficulties returning to the hospital due to lack of transport or job/family requirements during the day.

There are a host of things that I’ve taken away from this experience that I found profound, particularly as I reflect upon them having returned to my comfortable, efficient, wealthy hospital. The first is that it’s very difficult for me, as a surgeon, as one trained to be productive and to fix problems, to work in an environment in which efficiency is not optimized. I found myself, in Cambodia, constantly looking for the next case, trying to find more to do. The pathology is plentiful, but the resources and infrastructure are not: both on the patient side and on that of the hospital. The reality of this, however, was that I had to slow down and observe, think, talk to people and try to get the slightest sense of what it means to be Cambodian. More so even that operating, my favorite part of the day was board rounds with the staff surgeons, residents and medical students, the time each morning when we all gathered to review the week’s cases and discuss treatment plans. This was the time of day when I was most aware of just how much these well trained surgeons are forced to make medical decisions based on non-medical considerations: patients who cannot afford surgery with distal radius fractures get percutaneous fixation under regional anesthesia, patients who I would recommend for operative fixation with plates receive ex-fixes because no plates are available, anywhere in the country. It becomes difficult to define “standard of care”—that standard is so dependent, on patient finances and resource availability.

In the five years since I became a physician, I have, for the most part, stopped noticing just how profoundly our culture is intertwined with the way we practice medicine. The American medical infrastructure is enormous: it is legislative, administrative, medical, financial, intellectual, judicial and even religious. But what would medicine be if there were no government, no legal system, no money, no laws, no religion, no family? And how would you practice it outside of these entities?

When Pol Pot’s regime crushed Cambodia, it crushed not only a people, but an entire infrastructure. And now, thirty years later, the surgeons at Kossimak Hospital are desperately trying to practice medicine with an infantile infrastructure. There are patients, and there is pathology everywhere, and there are physicians who want to fight it. And in this situation, particularly as a surgeon, it is tempting to start formulating a plan—figuring out how we, as Americans or as western surgeons, can show these people how to succeed. But that is a delicate and dangerous thing. It is tempting to see the world in black and white, with good or bad fixation, with good or bad results—but this experience is teaching me that even those are relative.

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