By: Daniel Moon, MD
1/27/15
Well, I'm off! I'm about to go to bed in a San Francisco motel.
My flights were rerouted due to the snowmageddon hitting New York City.
Thankfully, things are working out as I ship off to Cambodia to join the
Cambodia Health Professionals Association of America (CHPAA) 2015 medical
mission to Svay Rieng province. I’m
excited that my father and I will be the orthopaedic surgeons for the mission
and that my mother will also be coming. I’m travelling on my own, and my first challenge is getting myself and
everything to the other side of the world.
Today, I spent part of the morning running around the entire
hospital complex trying to find my last shipment from Ethicon. After three
loading docks, I finally found it. I quickly went home, packed the contents
into my second suitcase, and my wife and I were off to the airport. Staring
down at the clouds on my flight from St. Louis, I realized how much more
reluctant I am these days to leave my family behind, but I recognize this is an
awesome opportunity, and I still feel very grateful for all the support.
Tomorrow, I hop on a plane to Inchon where I will breathe some
Korean air briefly and then transfer to the final flight to Phnom Penh. It
would be awesome to get some Korean food in Inchon, though, I may not have
time. Glutton.
I am a bit anxious about utilizing this mission time well. There is
so much uncertainty; much depends on the mission set up and the patients that
show up. A radio announcement soliciting patients went out to the province last
week. The organizers have assured me that there will be "plenty of
patients" – but they don’t know what specific diseases/problems will
present. My father and I have tried to
prepare ourselves for many possibilities. It's been very interesting to think
about the surgeries that we would like to do or definitely not like to do. Applying
for donation implants was a great exercise; I had to think about the most
useful/flexible combination of implants that would allow us to impart the
greatest benefit for an uncertain set of indications. The total volume of
patients is unclear, but I suspect that we will have to make some choices about
what conditions and patients to prioritize.
Time for sleep! Good night.
1/29/15
 |
| Team bus |
We finally reached Phnom Penh, and lining up to get off the
plane, and I start to worry about getting my suitcases through customs. I get
to the Quarantine Control station which consists of handing a travel form
to a pleasant woman standing by the door- I can't believe this actually works
to limit the spread of disease. Who
walks up and says, “Hey, I think I have Ebola, can you detain me?” Anyway, we get to the baggage claim area, and
this is the first moment of truth; will the $70,000 worth of donated equipment
actually show up in my bags on the baggage claim belt?
I get the first big duffel bag pretty early, which is great. Okay,
Trauma procedures can be done, check. Now, where's my bag with the sutures? Otherwise everyone is healing by secondary
intention.
I finally meet some team members here in the crowd. We find our remaining bags/boxes and we start
rolling over to customs. I'm expecting some built-up security area with lots of
table guards but it's just a couple of guys each with the table. We go up to one and hand them our forms. The customs officer has questions about the
contents of these large boxes. We point out the CHPAA logo and the Ministry of
Health forms take on the side. He's got a flat look on his face. The brothers
start taking out the list of contents to show him, he looks a little bit taken
aback. I decide to throw more bureaucratic/official looking paperwork at
him and throw in the list of implants. All this time, he hasn't said a
word. He looks at all this papers in front of him, seems to decide it's not
worth it, and simply waves his right hand like one dusts off a desk to
dismisses us out. We’re in Cambodia!
Outside, we meet another team member who came on the same flight. It turns out to be a radiology tech who works
with orthopedic surgeons in Seattle. This would be an amazing score for my
ortho plans, except I know that the Svay Rieng hospital has no fluoroscopy. So
close.
Driving through the streets of Phnom Penh in our bus at 11:30
PM, there's not much traffic. Our nice greeter tells us, in the morning this is
a madhouse. The capital has 2 million people. We get to the hotel, and it's
nice. I decide to keep all the stuff I brought with me-still paranoid. My room
is nice. 14th floor, Wi-Fi, polished
stone floor, air-conditioner, king bed, and widescreen TV. Oh yeah, really
slumming it now!
But this is just for now – Svay Rieng is not going to be anywhere
close to this. I take a shower, and
remind myself to keep my mouth closed in the shower from now on. I’ll do a
little laundry in the sink, and then I’ll go to bed. Good night!
1/30/15
It was interesting to think about the currency a bit. Here, one
dollar is roughly equivalent to 4000 riels. Other countries have
currencies that have settled out as thousands of units per dollar. But Cambodia
is one of these countries where smaller amounts of the currency actually
are meaningful to the locals.
Dinner was the first official event with most of the mission
participants. The bar on the hotel roof set up with a live band and a buffet. I
started meeting some other participants and further appreciated the diversity
of backgrounds represented here. I met a Korean American neurosurgeon who lives
in Phnom Penh now doing developing world education. He came to dinner because he is going to North
Korea with one of our current mission members in May. I also met a Korean-Englishman who is in the
middle of his surgical internship in England. He is planning to become an
orthopedic surgeon. Good choice.
There were plenty of others, including some that I had briefly met
in LA. There was a pharmacist, a hematologist from Stanford, a surgical tech
from LA (who I'm really going to rely upon), premed volunteers, a nurse, our
team anesthesiologist, and more. It certainly helps me appreciate how many
people it takes to carry out a successful healthcare mission trip.
After dinner, a large group of us decided to go to the waterfront.
We climbed into a bunch of tuk-tuks and rode out. We were warned about drive-by
purse snatchers. There were small piles of trash in the street and on the
sidewalks. Apparently the sanitation department only picks up trash every
several days. However, there are no trash cans, because they keep getting
stolen. It's rather unhygienic and must be bad for public health.
I left early to get back to the hotel lobby and wait for my parents
to arrive from the airport, who arrive in a taxi van. It was great to see them,
and they were in good spirits despite their own long travel. I helped them with their luggage, and wished
them good night. Tomorrow, breakfast and
then onto Svay Rieng!
1/31/15
Breakfast was a buffet again- my parents couldn't believe that most
of the people in the room were mission team members- they were surprised that
it was 50+people. In the hotel checkout line, we met a few more team members
including an RN who runs a telemetry unit and another dentist. Really nice people.
On our bus going down the highway, Suki Kosal and Visal explained
that this was Hwy #1, probably the nicest road in all of Cambodia, which leads
directly to Vietnam. Thankfully,
relations with Vietnam had been very good for a while and the road was in good
condition. Historically, the roads’
bridges had been blown up in times of conflict with Vietnam to prevent tanks
from rolling right up.
We got to a town called Neak Leung which had been bombed by the US
by "accident" during the Vietnam war. It is unclear whether or not it
truly was an accident as this is the site of a key ferry that has crossed the
Mekong River for hundreds of years. From the ferry deck, we could see a large,
modern bridge that was completed. There had been a ribbon cutting ceremony, but
the bridge itself was not set to open for another couple weeks. We were taking
one of the last ferries, therefore, after a hundreds of years. We all wondered
aloud what would happen to this town once highway traffic could simply roll by
and people didn't need to stop for the ferry anymore.
We were getting closer to Svay Rieng. Our experienced CHPAA leaders
Suki and her husband Kosal told some interesting stories about how CHPAA has
tried to remain politically neutral despite being courted by multiple political
parties after everyone had seen all the good that the CHPAA missions
accomplished. However, the CHPAA group wanted to stay neutral. I thought
that was a good idea given the importance of physicians being seen as caring
for the patients first and not a political agenda.
We reached Svay Rieng, and after quickly putting our bags in our
rooms, we walked to the hospital which was just around the corner. We arrived to see the truck being unloaded of
all the boxes, and we started helping. It was controlled chaos as the leaders
assessed the layout of the hospital grounds and the facilities. They started planning for where the different
medical stations would be. Dentistry. Glasses. Pharmacy. Medicine clinics. They
were trying to avoid problems in advance by strategically placing the stations
in a sensible flow. The experience of prior years clearly showed through; for
example, they put the glasses station away from the pharmacy distribution
center so that people waiting to get medications weren't going to be tempted to
ask for unnecessary glasses when they saw people trying them on nearby.
Boxes were divided by dental, medical, surgical, and pharmacy. Most
were pharmacy. Dr. Tan found a surgical team member who took us to the OR
rooms. There are three operating rooms, with reasonable set ups. Early 1960’s-era
equipment, but our room had an anesthesia station, a light, and even a basic lower
extremity traction set up. The
instrument room had four steam sterilization machines. We found the drill that
they use for orthopedics-a Makita portable drill with two battery packs. They
had been using formaldehyde to sterilize it. We will likely do the same and we
also brought my wife’s old Black & Decker drill to add to the rotation.
We cleaned out the staff room for all of our supply boxes.
Unfortunately, the two orthopedic contacts were not here today, one had a
wedding to attend, so we planned to meet them tomorrow.
In the midst of all this, Suki called me over into the building
where she introduced me to a couple patients who were already admitted to the
hospital. One was a small boy who had
fallen off his water buffalo and broken his arm. Prior surgeons put two "pins"in
his arm, and later removed only one. His right elbow is now fixed in about 30°
of flexion. I looked at his incision and was surprised to find a posterior
elbow incision as well as a second incision just 1 cm medial. I honestly couldn't tell from that what he had
fractured and what the surgeons had done for it. Clearly, we needed films. He
was NVI.
The second patient was a man apparently with a broken forearm. As I
asked questions with Suki interpreting, it became apparent that this guy may
have an infected both bone forearm nonunion. I asked Suki to tell him that we
would need to speak with their surgeons and get new x-rays, and then we would
decide what we could do.
As we walked away, I was excited that we had some patients to
consider, but a little worried because these are difficult problems. We spent a little more time sorting through our
surgical supplies and the local instruments preliminarily, though most of this
was going to take place next day. Dr. Tan brought our radiology tech friend
Mark to the radiology building, where I found that the little boy was going to
get some x-rays. The radiology tech had a literal dark room for developing
films. He also had a portable x-ray
machine, as well as a shielded x-ray table. A Japanese group had provided all
this equipment. We requested an elbow series and to my chagrin there was a
flexible nail embedded in the patient's distal humerus. It really wasn't clear
what fracture has been addressed, but my sense was that it wasn't a
supracondylar fracture. The lateral condyle did not look good and there
was some unreduced fracture fragment in the anterior fossa. My dad and I
discussed it, and we worried about disturbing the growth plate with the removal
of hardware procedure. So, we tentatively told the family that we probably
weren't going to go remove the nail and that he will probably need to focus on
nonoperative exercises to restore range of motion. We warned them on the
potential for long-term deformities in which case an osteotomy would be needed.
My parents were a little distressed about the geckos in their room.
We went to the main hotel, where we had a banquet dinner honoring the local
doctors and hosts and local Ministry of health officials. Dr. Tan also
introduced the entire CHPAA team, which was nice. A few of the Cambodian
medical students sat with us at our table. Two were pharmacy students, and two
were medical students. Drs Kenton and
Neil Wang sat with us as well. We had carp, shrimp, rice, and some soups. For
dessert there was some fruit, including a lychee-like fruit. The local administrator
was given an opportunity to speak, and he went on and on and on. I can kind of
fell asleep but woke up to clap. We got on the bus back to the hotel, I traded
rooms and the parents because they were still worried about the geckos.
2/1/15
We had breakfast in the main group's Waiko hotel this morning. The
food was pretty slow in coming. The surgery team had a meeting after breakfast,
and I was asked to lead the surgery team by Irit and Dr. Tan. Irit said that I
was young, and would be interested and able to do a good job. I accepted the
offer. We passed around a sign-up sheet for the surgery team. We had recruited
a couple nurses from the general team for preop and a couple nurses for the OR.
I had told two of the US premedical
students that I wanted them to help me. I went over a quick plan for our day at
the hospital to prepare for the coming week. Dr. Michaels, the general surgeon,
made a good observation that we weren't here to get hurt nor should we hurt our
patients. I told everybody that we would meet after dinner for a group update. Safety #1.
 |
| Being asked to lead surgical team |
Again, there was a lot of uncertainty with respect to our surgical
team setup and plan – we did not have the routine setup/stations that the
medical team had. We were playing it by
ear, to a degree. It was all very
exciting, and you could see that we were developing some pride in being on the
surgical side.
We went back to the hospital, where we started unpacking the
surgery boxes. My main goals were to figure out the logistics for all of our
surgery patients. Where were they going to come from? How would we see patients and book them? Where would postop patients stay? Would they be admitted? What was the process for getting inpatients
from the main facility to the surgical suites?
I tracked down Dr. Kim, the local Cambodian surgeon. He is a surgeon in the classical sense – he
does appendectomies and also the orthopaedic procedures. His ortho training consisted of a year in
France.
I need to find out what their typical flow of patients was. I
discovered that they had their own pre-op area in the main hospital building.
From there, they would walk the patients through the dirt courtyard to the OR's
for their procedures. Most of their preop patients were already living at
the hospital. They did not have same day surgery.
 |
| Reviewing issues with coordinators and schedulers |
I was very impressed with how the surgery team got our supply room
organized. They used boxes as
rudimentary shelving. We took stock of what we had.
I rounded with Dr. Kim on all their potential surgical patients in
the hospital, and discovered two trauma patients that had just arrived within
the past day or so. I decided that we
would start our OR with a distal tib-fib fracture and distal humerus fracture
orthopedic cases on Monday.
Willy (scrub tech) and Sophia (PA) worked with the instrument staff
and also educated our surgical team’s Cambodian medical students on how to
watch the autoclave machine. I asked Sophia to take charge of the medical
students rotation through the OR and other parts of the surgical team
throughout the week. She spoke fluent Khmer and had already started to get to
know the students. There were six of them. I got their names as well. One woman
and five men. They were enthusiastic to
help us, but I didn’t know what their experience level was or what they were
capable of.
We were allowed to use two of the three operating rooms. The local
hospital needed to keep one OR for emergencies and for themselves. I talked
with Dr. Michaels and we agreed on which room would be better for general
surgery vs ortho. The OB-Gyn would be joining us tomorrow, and the
preliminary plan was for Gen-Surg and OB-Gyn to split a room, with ortho in the
other. We talked with the team leaders,
and they set about hiring an additional local anesthesiologist to help staff
the second OR. Willy started training Kory and Lauren on the basics of scrubbing
and instruments. I went through a lot more of the local hospital's trays to see
what instruments they really had available.
Meanwhile, my mother has been recruited by the pharmacist Githika
the night before to help her in the pharmacy. I was very happy that my mom had
found a role. Eric and Suki worked on figuring out how to get patients registered
and the forms we would need. CHPAA had consent and pre-post op order
forms that they had used before, which I thought were adequate. So we ordered
many more copies.
Dr. Barnes and I each had a key to the supply room which would be
locked every night. I picked out the screws that we would need for the cases
the next day. Willy had the great idea of using masking tape to label the
screws. Corey and Lauren went through all the screws I had pulled and labeled
them all. One case was Synthes, the other was Smith and Nephew. Just like at WUSTL! We had our own trays
pretty much set up for the next day. By the late afternoon, it looked like we
had prepared reasonably well. We went to a new location for dinner, which
was in a real restaurant and delicious.
After some announcements at the end of dinner, I called for a
surgery team meeting. I shared with them
what I had learned about the local hospital’s setup and what our general plan
of attack was going to be. The team was energetic!
2/2/15
Woke up this morning to the sound of a rooster half-crowing,
"Cock-a-dood-". It was annoying that it wouldn't finish the last
couple syllables/sounds each time it crowed.
Breakfast at the hotel was a little disorganized, there was only
one cook. At the end of breakfast, the surgical
team was among the first to leave for the hospital. Our first surgical patient
was a 50s-year-old woman who had an intra-articular distal humerus fracture. We repaired it with screws and plates. It was
a bit inconvenient that we didn't have every single screw length (I skipped
lengths in my request intentionally to simplify the request and supplies), but
we made it work.
A surgeon friend of Dr. Tan had driven down from Phnom Penh to
observe our surgery. He was a professor of orthopedics in Phnom Penh. As we were
putting the plate in, he remarked that it was the first locking plate in Svay
Rieng- ever.
Our group of Cambodian medical students and US premeds observed the
surgery. Some other local Cambodian staff also joined out of curiosity to see
what we were doing. The case went well
and I was pleased with the result. Our
second case got bumped by an emergent appendicitis – again, just like home. During
our case, the general surgeon and the gynecologist had added on a lot of
procedures. We came out of the OR to see that the board was full of
cases!
While we waited for our next case, my father and I started seeing
patients triaged with surgical issues from the main medical clinic, which was
processing hundreds of patients. The very first patient I saw was a seven
month old boy who had clubfoot on the left foot but only four toes. I
knew nonoperative treatment should take care of this very well. However, I was
uncertain as to how to get him to the right people. We didn’t have enough time to do the full Ponseti
casting course ourselves. I sent them to
get films to make sure that there wasn't an issue with the fibular development
or other abnormalities other than clubfoot. Thankfully, the visiting professor
from Phnom Penh told the patient’s family that there was a person that he knew
in Phnom Penh who could do Ponseti casting properly. The patient's family was informed and given
that plan, much to my relief.
One patient had a right elbow fracture over 10 years previously
with very bad nonunion and capitellar erosion. He's range of motion was limited
to just several degrees of motion. But he did not have much pain. He was a
farmer, and more concerned about a bump on his neck as opposed to his elbow, so
we decided not to do anything for is a go even though we might have been able
to give him better range of motion by relocating his elbow and advancing his
lateral condyle, his motion may have been painful, and that was not worth it.
We booked a few cases for later in the week; a man with an
unexplained plantar foot mess without any radiodensity on x-ray but impairing
his ability to walk. We booked him for surgery tomorrow. There was a girl who had been pushed into a fire years before, and
had subsequent palmar skin contractures. We booked her for Wednesday. That would be a complex case given her
contractures of the index through small fingers. However we felt that Z-plasty could
help at least one or two of her fingers. We may not try to release all of them,
but it will depend on how the index finger goes - my father was really moved by
her case, given her young age and presentation.
I checked in on my mother, who was doing well working in the
pharmacy area. She was doing a good job of blocking unintended snooping or
theft. My mom is a tough woman, a monk very fluent in English, came in request
and showed a fungal growth on his thumb. He requested a sample of antibiotic
from the pharmacy. However my mother knew that 1) this was probably not the
right treatment and he should see one of the doctors in consultation, and 2)
that there should not be any direct dispensing from the pharmacy. So she kindly
told him to go out and register like all the other patients and see one of the
physicians. He tried to get around this but my mom was insistent. He left and
returned with six other monks including the head monk who demanded that he
received medication. However, my mom remained adamant that he go outside,
register, and be seen like everybody else.
The pharmacist then showed up and agreed with my mother. So the monk
went outside and registered like everybody else and eventually got the proper
antifungal medication.
There was the man with a nonunion of his right radius and ulna
after a failed ex fix who had come up to us on the first day. The local
physicians had told the patient to wait for us and that we would fix it because
they did not want to do it. However, I wasn't very interested in doing an
infected nonunion either, so I had told him that maybe we do it later in the
week and moved on. However, all throughout today, this patient kept finding our
very nice Suki and begged her for us to do something. So, we saw the patient in
our clinical exam room, and I was happy that the wound itself did not look too
bad, however there was a concerning area of fluctuance. The ulnar incision had
healed very well. There was no overlying erythema, so we added him on as our last
case tomorrow, with the plan that if it looks uninfected after IND tomorrow, we
will wash it out again and fix definitively on Friday or Saturday. If, however,
it is infected, we will do a thorough debridement and then probably cast him
and have him treated definitively in a cast, or the definitive treatment after
resolution of the infection to the local physicians. However, that is very
unlikely, because he does not have access to proper antibiotics to eradicate an
infection, nor are the local physicians interested in trying this case it
seems. We'll see.
There were a lot of lipomas that the general surgeon or the primary
care physician are removing. Our last patient to present today was a recurrent dorsal wrist
ganglion. The OMF surgeon on the mission
joked that if we did not do it, he would. I laughingly told him that was a bad
idea, and that this should probably not be done under local because we would
need to go deep. So, we added her on for Wednesday as well.
I was a little annoyed because my second case (tib-fib fx) was
delayed by another hour because the second drill had been opened as the first drill
battery power was giving out. But, I had only said to have the drill ready, and
not open. They can only sterilize the drill with formaldehyde, which they say
takes eight hours. So, finally, we proceeded with our distal tibia case. It
worked out well, because we were back in a regular room and had Angelina's as
our anesthesiologist, and of course she is amazing. She was able to relax our
patient as well at the time of reduction which made a big difference.
I was worried that the plates I had selected wouldn't be adequate,
but it turned out that the anterolateral plate was absolutely perfect for this
fracture. So, at the end of the case we had directly reduced much of the
fracture with the exception of the posterior this fragment distally.
However, before we can do high-fives, will need to get new x-rays. Still,
I'm optimistic though my biggest concerns are swelling and infection. Of
course, we are having them receive IV antibiotics for three days and we'll see
what the films look like. After this case was done it was about 8:45 PM.
Suki had procured some dinner boxes for us to eat, so Willy Lauren, Kori, my
dad, and I were able to eat some rice and salad and squash and chicken soup. It
was delicious.
At the very end of the day, I picked out the screws that I needed for
tomorrows case. Willy and I took the screws out of the packaging and taped them
together by size and wrote on the labels based on the same idea that he had had
the day before. It had worked well today to keep things moving and avoid
checking sizes despite not having a screw caddy. Another example of a move on
the fly. Some of the little pearls, include my dad’s sponge between the handles
and clamp check for making bone clamps work across large distances. Using
a sphygmomanometer pressure cuff as our Tourniquet. Using Angeline's suitcase
strap as a surgical table safety belt. And of course, I can't forget that we
are using my wife Anna’s old Black and Decker drill as our main drill in all
of these cases. Who would've thought? All in all, a great day. Even if it did
go long. We scheduled things a little more stringently for tomorrow so the
whole team isn't as tired at the end of the day. Let's see how it goes.
2/3/15
I designated a premed Justina to be Willy’s assistant in managing
supplies in the hallways while he is scrubbed in, given her ability to speak
some Khmer and she interfaces well with our team.
It was getting to be nearly 7 o'clock so
I canceled the last two cases, including our irrigation and debridement of the
forearm and one inguinal hernia case. One doctor complained to me because
she really wanted to scrub assist with the inguinal hernia. However I could
tell that the staff or really tired, and given that we had worked really late
the prior night, I thought it was prudent to call it for a day. I think the
staff appreciated it.
2/4/15
It was 4:30 AM and the rooster was already crowing. I
looked up some notes. I went to my parents’ room and my dad and I debated that
direction and types of Z plasties that we would use for the burn patient. This
discussion went on too long and it was 6:20 AM. I had to skip breakfast and get
directly to the hospital.
At the hospital, I gathered some dressing supplies after unlocking
the supply room and then went to round on my postop patients. The tibia ORIF
was doing well. He had some minimal drainage but the overall wound looked great.
He was apparently getting his ancef.
I saw the older woman with the elbow fracture. She was moving her
fingers fairly well and did not look uncomfortable in her bed. Next to her was
the radial malunion patient. He was also moving his fingers well. The little
girl in the cast was doing pretty well. I asked the resident to get new films
sometime. I also asked him to get new films of the distal tibia. He said sure.
After rounding, I went back to the OR where I got dressed in scrubs and started
helping folks with getting ready.
Suki and my mother were nice enough to bring me a bag of bread and
egg pancakes for breakfast. Dr. Hunter offered to convert the cash that the surgeons at
collected as a tip for ours Cambodian stuff into riels.
Today was going to be a busy day for Dr. Michaels, since he was
leaving tomorrow morning. He had four procedure
scheduled in one room with a small dorsal ganglion by my father and I in
between.
The first case was an irrigation and debridement of the forearm
nonunion. When we took the patient's bamboo split off, we noted that there was
some pus draining from the proximal aspect of the wound. Thus, we knew we would
not be putting in any fixation today or later this week. We opened the incision
and found frank pus tracking more proximately via a sinus. We exposed the fracture and found that he had
some fibrous callous but nothing bony at the site of the fracture. It was
notable that the external fixator pins have been placed very close to the zone
of injury. We debrided extensively, including the canals. We decided that our splint would likely be
his definitive fracture treatment. This was far more rigid immobilization of
his fracture than the bamboo he had previously, so he may actually heal this
with bony fusion as opposed to just fibrous nonunion. In America we would've
given weeks of antibiotics and then definitive fixation. However, I gave this
gentleman a 2-wk oral antibiotic regimen to help suppress his infection and
give him a head start on healing. Hopefully he will have a chance at a
noninfected union, but as a fallback, he still might heal the bone in an
indolent infected setting. If that happens, perhaps someone will be
willing to just wash out his infection in the future if his bone heals.
Our second case was later in the day, so we had the morning to look
at clinic patients. There were a few
joint pain patients that were booked for Thursday's series of joint injections.
I was asked to look at a few general surgeon patients, including a bad case of
umbilical and scrotal herniation. I politely deferred the patient to our
general surgery colleague!
Our second case was the very difficult case of the flexion
contracture after an electrical burn five years ago. This was a 15-year-old
female who had contracture of the index long, ring, and small fingers. I had shown
my father the box-type syndactyly release that Goldfarb uses in the Shrine. We combined those with Z-plasty's and got all of the digits straighter.
While all the digits were not perfectly straight. We traded off between
getting all her fingers to a functional position versus getting a couple
perfectly straight. My father felt that we put in over 100 sutures. He might be
right. The case took over four hours,
but at the end of the case all her fingers had good capillary refill and we
could get her fingers fairly extended.
It was very late when we finished the case, though. So I canceled
the last case in our room and moved it to tomorrow, being respectful to the
team. The patient would stay in the
preop area overnight.
We actually got out of the building in time to go to dinner. When
my surgical team entered the restaurant for dinner we received a large round of
applause since we hadn't made dinner as a team since the beginning of the trip.
Dinner included a delicious curry. The surgical team was happy and laughing.
2/5/15
Woke up this morning with the rooster again. Willy and I were the
only ones on the 6 AM bus to the restaurant. Of course, Dr.
Barnes our anesthesiologist was already there, and breakfast was coming. We took the mini bus to the hospital, where another large line was
seen outside of the building.
Our first case was left over from the prior day; a dorsal ganglion.
It was a very large dorsal ganglion, and my father and I did the case together.
A prior surgeon had used a longitudinal incision to get the dorsal ganglion
out, which may have indicated some degree of unfamiliarity already. A re-occurrence, thus, was not as surprising.
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| Teaching medical students during a case |
We had another of the Cambodian medical students join us. For these
students it is often the first time they've ever scrubbed in; hopefully a great
experience for them.
Our next two cases were supposed to be carpal tunnel releases, but
neither of them showed up so we proceeded with another dorsal ganglion in a
pregnant lady. We did a Bier block.After this case, it was time to do the
seven-year-old boy with the limited elbow range of motion and the retained
flexible nail. His range of motion was limited from 45° to 90°. After surgery, though, ROM was nearly normal.
2/6/15
Woke up and went to breakfast just a little later. It was my dad's
time to lecture today so he only came to breakfast very briefly. At the last
minute, the course director’s Flash drive with my dad’s lecture did not work
well so I ran to the hotel to get my dad's thumb drive and eventually
transferred his files over to the presentation computer. Unfortunately, the
layout was all jumbled due to the format differences. I will have to take
precautions to make sure to make sure that doesn't happen to me tomorrow!
I was really sad because my safety glasses were nowhere to be seen.
Someone I think had taken them from the call room. So I went back and got my
regular glasses on for some eye protection.
Our first case of the day was a dorsal ganglion in a man. I had Eric
first assist me. Eric has worked really hard this whole week, putting up with a
lot of stress and has done a good job of staying on top of it. My father and I
both agreed that he deserved some good OR time.
We saw a consult of a little boy who came in on a motorcycle with
his father. The boy’s right knee was gigantic. It was Osteosarcoma - The
patient's family said he fell off water buffalo in September and was seen for
her right knee pain at the local hospital, who said that he was fine. 2 months
later they noticed enlargement of his knee and then went to a Vietnam hospital
which did an MRI and said it was cancer. The doctors said he should get chemo
and amputation but father refused because he didn't think amputation made sense
since his son could move his leg/foot well. They got some traditional alcohol
needle puncture treatments but did not seek any other can't talk today. Now, he
shows up with a gigantic lesion. It was a difficult conversation for all of us,
but we told the father that his son needed proper medical treatment and surgery
immediately or he would die. We needed advanced imaging to stage the cancer and
to decide whether the patient needed an a.k.a., disarticulation, or if it was
too late. We recommended that the patient go to Phnom Penh to the Children's
Hospital there that we have been told that can provide free care and has
advanced facilities. Our volunteer nurses were really moved by his case
and raised nearly a $100 to help him get to the capital city.
I nearly broke down into tears while talking with the father. I
have been pretty unemotional, but briefly thought about my own children and the
prospect of them in a similar situation. It was also so tragic, because I felt
like this patient's son will likely die because the father had not been
properly educated about the serious condition and/or had assumed that a good
foot meant that the leg could be saved.
We are running out of time, so we did not book too many lumps and
bumps. However, I did book a soft tissue mass excision for the procedure room
because it was directly over the fourth webspace of the left foot and
interfering with shoe wear.
For our second case today, we did a revision retrograde femoral SIGN
nail with Dr. Kim, the local surgeon. The nail had not been inserted deep
enough and the head was blocking the patella. We were fortunate in that my
father had shown the case to Dr. Kim who immediately volunteered that he had
done the case; so we could be careful in how we described the case to him. This was clearly a mistake in technique, but
he did have some explanation in that the proximal femoral shaft was so bowed
that he could not advance further. Also, his assistants told him that there was
no shorter nail available. However, for this case, we looked through the trays
and did find a shorter nail to use, so we proceeded with a new exchange
revision. It was fun to see the SIGN nail system go in and play with it in a real
patient setting. Eric also scrubbed this case.
For our third case, we did a right elbow release in an untreated
fracture dislocation. I started the case with only Eric because I thought
my dad was in the small procedure room. However, it turns out that he was
napping in the surgeon changing room. Suki was so nice and had protected him
from being disturbed. He finally arrived at the time that I was exposing the
coronoid medially. It took three hours
total, but we finally finished the case with a great ROM result, at least
intraop. We got the patient nearly full range of motion after moving his
coronoid proximally and relocating his joint and reconstructing the lateral
collateral ligament.
At the end of this case, my father brought in a set of x-rays
showing a tib plateau fracture from a woman who had gotten into a motorcycle
accident on the way to our clinic. He wanted to add her on. I asked him to
check the soft tissues and he said she was fine. I was not excited about adding
on a case that would undoubtedly put our team out too late. I suggest we add
the case on for tomorrow, but my father prevailed upon me to do the case
tonight, as our ability to operate tomorrow was uncertain.
Next, we had the monk case. This gentleman had rolled over in sleep
and embedded a needle in his right buttock. The needle itself was not in a
terrible place, but the patient had already had two surgeries by the local team
to remove the needle. However, they could not find it. On exam, the patient’s
surgical wound was draining pus. I was worried about a deep abscess. The
patient confessed that he had spiking fevers. Thus, we booked him for
irrigation and debridement of his surgical wounds, and removal of foreign body.
I had Navy, our most spectacular Cambodian medical student/resident scrub this
case with me. We had repeated X-rays
using a penny as a marker for where I thought the needle was. I felt pretty confident that I knew where the
needle was. I asked Navy before the case how long she thought it would take me
to remove the needle. She said 20 minutes. I said I would get it out in less
than five minutes. She laughed.
It took me less than two minutes to find the needle and remove it.
It was essentially more superficial and medial than the local surgeons had
thought. We washed out this wound and closed it, putting a Tegaderm on top.
Then we removed the dressing from the dirty wound and irrigated and debrided
that surgical wound. Indeed, there was a deep abscess with plenty of pus. We
thoroughly debrided that wound and loosely closed it.
Finally, we did the tibial plateau fracture. My father wanted to do
a Y shaped incision. I argued that because of the fracture pattern we need to
do a posteromedial plate with the medial side incision and a separate lateral
incision. We disagreed but I insisted on the double incision approach. I
figured that is what Drs. Ricci and Gardner would do. The case took a
while, partially because we were all tired. I took care of the medial side. My
father took care mostly of the lateral side. However, I came over to the
lateral side and insisted on getting a better articular reduction, getting in
my Father's way to a degree. Still, it all came together very well with
our combined efforts.
It was nearly 11:00 PM. Our team was definitely tired, but happy with
the case. Suki had saved us some food. We took some group photos to commemorate
the end of our surgical week.
I was pretty exhausted and went to the hotel and slept right away.
Bye now, I had gotten smart and is using double blankets to make sure I
wouldn't get too cold with the air conditioner. The gecko said good night
too.
2/7/15
After a quick breakfast, I came quickly to the hospital, where
there was, again, a line of patients outside the hospital grounds. These were the overflow patients from
yesterday who were promised a visit today in the morning. No other new patients were going to be seen,
as we needed to breakdown the setup and drive back to Phnom Penh in the
afternoon. I was in a hurry to get my PowerPoint
presentation setup for my lecture to the Cambodian medical students and local
residents and physicians. I had selected
the topic of Orthopaedic emergencies and wanted to focus on a few problems that
local providers and non-orthopaedists would likely encounter but could also
treat/triage appropriately.
I tried to speak at a reasonable rate and to put lots of useful
photos in my presentation. Of course, my
surgical med students were all there and attentive – as I’d told them to
be. More surprisingly, though, a lot of
the other students appeared to be following along with interest. These students had been working hard all week
seeing patients, directing patient flow, translating, delivering supplies, etc.
Each morning they had two lectures from members of the mission team. Most of the lectures were medical, but each
of the surgeons also gave a lecture. I
was lecturing on the final morning of the final main mission day. I was surprised by how many students still
came and was happy they asked questions afterwards. One of the local residents asked a good
question getting to the next level of issues/ortho-specific, which was good,
too.
After the lecture, I shed my white coat and got back to the
surgical team issues. Most of the team
had been cleaning up the supply room. We
had planned to donate the remainder of nearly all of the supplies that we
brought to the local hospital. I was
doing the same with the ortho implants, but I made sure to track down Dr. Kim
and his colleagues and gave a mini-lecture about each of the implants,
particularly the locking plates, to ensure that they had an idea of how to use
them appropriately. In addition, my
father and I went on a final rounds with Dr. Kim and his staff (along with our
surgical med students) to go over postop and rehab plans for all of our
patients. I was definitely cognizant of
the problems that we could cause if we neglected to provide good postop plans,
so I had hand-written postop plans for each of our ortho patients from the
week’s surgeries. As we went over each plan, I gave each sheet to Dr. Kim’s
team and made sure the patients and their families had a rough sense of what
was planned for them.
Finally, I got a couple of final postop films on a couple patients
from the day before, and we were pleased with the results! We said farewell to
Dr. Kim and his colleagues, went back to the hotel, and loaded our bags on the
bus. Back to Phnom Penh!
2/8/15
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| Cambodian Minister of Health gives thanks to the team |
Last night, we had a team celebration at a restaurant. The Cambodian Minister of Health personally
thanked our team, and the medical/dental students received their certificates
of participation and education. Our
surgical students were sweet and bestowed each surgical team member with a gift
scarf, which we wore with pride. It was
a terrific time to recognize what the group had accomplished not only this
year, but cumulatively over all the years.
I met the Cambodian orthopaedic society’s president and showed him some
of the cases that we did in Svay Rieng.
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| Surgical students and the Moon's with scarves |
After dinner, I went out on the town with some of our mission team
members and medical students and had a good time dancing, sharing some drinks,
and hanging out. It was great to have
some dedicated fun-time with my team.
Got some late-night pigs feet and noodles. Good times.
This morning, the subset of the mission team that was going on the
tour of Siem Reap packed the little bus up for our trip. Then, we set out on an 8 hour drive. Along the way, our bus ran out of gas, but we
got things going again. A couple of my
teammates ate some tarantulas at a rest stop, and we also got some Korean red
bean popsicles at another rest stop. Fun
times. We arrived at our hotel in Siem
Reap. Most of this portion of the trip
was recreational, but a couple clinical stops were planned, and I’d been asked
to help a bit.
2/9/15
I accidentally overslept this morning. The bed is ridiculously
comfortable. I made it down to the lobby just in time for the originally
scheduled bus pick up, but there was no bus. So I went to the breakfast area
and had a crêpe with papaya and chocolate, and also a croissant and roll. Clearly, the Siem Reap area was designed to
cater to the tourist crowd and their desired amenities!
We got on the bus and drove to a pediatric hospital run by Japanese
photographer. However, once we arrived we realized we were one hour too early
for our appointment. We needed to drop off some hand clinic supplies to the
prosthetic hand team so we went there on the way to the Swiss run hospital.
However, I decided to get off with the hand team because I was interested in learning
more about the hand prosthetics. The
whole time we had been in Svay Rieng, the hand prosthetics team had operated a
station in the medical clinic outfitting amputees with a free prosthetic hand
that had been designed with the CHPAA folks in cooperation. Unfortunately, I hadn’t been able to participate
in their work in Svay Rieng due to my work on the surgical team. This was a good chance to learn more.
The hand prosthetic team was meeting with a local foundation called
the Shinta Mani Foundation in order to train local workers on how to fit
patients for the prosthetic hand. There were several patients at the meeting
today. The first patient they were to fit is also blind. He currently works as
a singer in a local amputee music band. Teri had run into him the year
before and told him then that we would be coming back with prosthetic hands.
They had found him again this year and he was still interested.
A Cambodian medical student who had done the fittings for patients
in Svay Rieng demonstrated the hand. We
fitted several patients with prosthetics there and I got a good chance to examine
the prosthetic design and help put it on patients. There was a small issue with the limb sock
not fitting on one patient, but I put some pie-crusting to work, and we got it.
Haha
The blind amputee was very happy with his hand and sang a song for
all of us. Another patient, a young
child, was fitted with a prosthesis. He
put a water bottle into the prosthetic hand and realized that it would actually
work. Suddenly, he was grinning ear to
ear. His mother was very happy, too.
After the hand prosthetic training session was done, I
rejoined the remainder of the group on the bus. We went for lunch. Another
buffet, of course. Excellent. We then went to Angkor Wat at sunset time to
watch the building change with the sunset. It was impressive. We had dinner
at a restaurant where there was also a dancing show. Then, we went out for some
shopping. My mom loves to bargain with
shopkeepers. We got a ton of scarves –
no surprise. The shopping area was
surprisingly Western, and I found it less interesting than the Svay Rieng town
we had been in. While tourism is an
important revenue source here, it was a bit strange to see how this area was
designed for a non-Cambodian crowd.
2/11/15
After breakfast, I went to my parents’ room and encourage them to
pack. I brought my bags down. I then went with Teri to a local hospital to help
her look at a bilateral upper extremity burn and amputee patient that she had
heard from another doctor. The patient was potentially interested in our
prosthesis. We took a private car and to
the Siem Reap Referral Hospital, which I recalled reading a little about from
the SIGN website. There, we found the patient in question who had been
electrocuted near the Thai border and lost both of his hands at the mid
forearm. We were pleasantly surprised to learn that he had already received one
of our prosthetic hands from a partner group. However, he was not using it much
right now. We told him to be cautious in using it too much; we recommended some
daily practice but no extensive use until his stumps had more time to mature.
His primary active issue is that he has an open wound on his distal tibia which
has exposed bone. They are searching for help with regards to soft tissue
coverage strategies. We found the local orthopaedic surgeon, and he and I
discussed the patients’ options. The
doctor was thinking about a cross leg flap, which I have not seen before. I
asked about pedicle flap or even a free flap, but he said that he did not have
much experience with flaps in general and was looking for help from the Hope
Hospital in Phnom Penh.
He mentioned another patient upstairs who also had bilateral upper
extremity amputations. This patient was slightly older but had been in the same
accident. He also had an amputation of his left first and second toes and
appeared to have more extensive burns on his abdomen that were still healing.
The left arm had had an above elbow amputation and appeared to still have healing
burns or wounds.
Unfortunately, he's right forearm amputation had a very
prominent bone spike on the ulna with blanching skin overlying the point. I
pointed out to the surgeon Dr. Radda that this point would need to be removed
with a subsequent surgery such that the stump could be placed in the prosthetic
without damaging the skin. He saw my point, and he said he would perform such a
surgery later on but in time for June, ideally, when the prosthetic hand team
would return.
The physician wanted to show me an x-ray and ask a
question about another orthopedic patient. It was a patient who had been in a
motor cycle accident and had an open fracture of the tibia with a segmental bone
loss of the tibia and fibula and a continuing open defect. The patient was still
in an external fixator. To address the limb length deficit, the physician had
done proximal and distal tibia osteotomies with some local distraction/lengthenings. However there was a 6 cm deficit remaining
centrally. I discussed four different limb-salvaging options with him. One was
a fibula vascular graft, but I said this would be very difficult and not a
great option in the setting of an ongoing infection. Next, I mentioned that he could simply bring
the proximal and distal and ends together and get that to heal in continuity.
He agreed with me that a noninfected short leg was better than a chronically
infected longer leg. Next, I mentioned a Masquelet technique with cement.
Finally, I mentioned the option of bone transport with an external
fixator frame and 1 mm daily distraction. I told him these were all difficult
options. Frankly, amputation might end up to be the best option, and we briefly
discussed that too. He was appreciative
of the feedback/ideas, and we excused ourselves from the hospital.
We came back to the hotel, and my parents and I took a
tuk-tuk to the nearby North Korean restaurants that I had heard had some
interesting dance shows and food. I
wasn’t sure if we should go inside but I did want to see the places (Cambodia
has had interesting relationships with North and South Korea), and unfortunately,
the restaurants were closed, and we just took pictures outside. Back at the
hotel, we had to get our final belongings together. We then took a van to the
airport. At the airport, we were happy to see that we were boarding a full-size
jet Airbus. The flight was terrific; we got a brownie and water mid-flight. The
whole flight took about 35 minutes. That was much better than the 6 to 8 hours
we would have had to spend in the bus. When we landed, I withdrew some more
money, then we got into another van with a tour guide and headed towards the
killing fields. My dad was trying to get more information from the guide and we
started asking him questions about Cambodian history. It soon became a prologue
into the rise of the Khmer Rouge.
I learned a lot about the history of the Khmer Rouge
and the recent history/turmoil seen by Cambodia. Without going into it too much hear, I was
sobered by the vivid accounts of modern-day genocide that occurred here and
which explained some of the challenges continuing to be faced by Cambodia
today. It was moving, and like many
international experiences, showed me again how fortunate we in the United
States are.
That night, I had a final dinner with the team, and the
medical students met us outside the restaurant to say good-bye. Their enthusiasm is infectious, and as I look
at them, I cannot help but feel that the future of Cambodia will be brighter
because of them. More than any of the
surgeries or clinical care we delivered this past week, the education we provided
for these students will likely be the most impressive legacy of the work we
did.
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