Wednesday, May 27, 2015

Svay Rieng Province, Cambodia for the 2015 CHPAA Medical Mission Team

By: Daniel Moon, MD

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.

Team bus
Got some bibimbap in Inchon, S. Korea.  I tell you, Asiana airline's reputation for excellence service is well-deserved. Those flight attendants were going up and down the aisle all the time with juice, water, food.  I showed remarkable restraint and only watched a few movies on the way over.   I watched the Brad Pitt Fury movie. A little predictable and formulaic, but appropriately depressing, which is what most of those war movies should be. I appreciated Asiana’s complementary slippers that they provided, particularly since I hadn't been able to buy flip-flops despite visits to multiple St Louis stores. Apparently flip flops are not a popular purchase in the middle of winter.

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!

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!

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.

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 decided that we needed our own mechanism for preoperative preparations, surgical consults in triage, a scheduling.  We would also need some space for small procedures and critical examinations.  I went through the surgery building ground floor with Dr. Kim, and we designated/converted rooms for these activities. His cleaning staff got to work cleaning out these rooms for our purposes.

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!

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.

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.

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.

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.

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.

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.

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!


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.

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.

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.

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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