By: Steve Cherney
With the support of the Washington University Department of Orthopaedic Surgery, I spent two weeks visiting Preah Kossamak Hospital in Phnom Penh, Cambodia as my international rotation. Phnom Penh is the capital and largest city in Cambodia, and is home to approximately 2 million people and 14% of the country’s total population. The city is geographically similar to St. Louis. Phnom Penh is in the south-central area of the country, at the junction of two large and economically important rivers, the Tonlé Sap and the Mekong Rivers. The city is very densely populated, and is in the midst of an economic boom fueled by the garment and tourism industries. Despite recent economic gains, the country has been historically very poor, and much of the country lives in poverty and are still agrarian based.
My contact with the hospital was made through the SIGN Network of surgeons and the help of Dr. Lewis Zirkle, who is the founder and president of SIGN international. The SIGN nail is a family of intramedullary implants that were designed as a modern intramedullary device that can be placed without intraoperative fluoroscopy, as many developing countries do not have ready access to such imaging. The devices are solid, non-cannulated nails that rely on aiming arms for distal nail locking. The SIGN program at Kossamak is well-established. The relationship between Dr. Zirkle and Dr. Duong Bunn dates back to 2003 and has been an example of one of the most successful partnerships in SIGN’s history.
Kossamak Hospital is a public hospital that relies primarily on government funding, supplemented by other non-governmental aid organizations including the SIGN program. The Orthopaedic Surgery department is one of the largest departments in the hospital, and are led by Dr. Bunn. Under his leadership are 8 other orthopaedic traumatologists. The department also has started a residency program, and is set to graduate their first set of residents this upcoming fall. The orthopaedic department also oversees the plastic surgery service and their residents.
As in many other developing countries, the vast majority of orthopaedic patients are seen as consultations for motor vehicle or motorbike trauma. Many of the injuries seen in the hospital are transferred in as orthopaedic polytrauma patients from the other outlying provinces throughout the country. The orthopaedic service has 80 beds in the hospital, far more than any other individual service. As in many other countries, the population has a safety net for all patients in the form of basic universal healthcare, and this can be supplemented with secondary insurance if patients can afford it. Similar to this country, the patients that are most commonly affected by trauma often have the least economic and social support. As a result, the hospital and the staff at Kossamak end up taking care of the poorest and most seriously injured patients.
There are up to 4 residents in each class. The majority of their training focuses on Trauma, although there are separate rotations at outside facilities to gain exposure to other subspecialties such as hand and soft tissue reconstruction, arthroscopy, and arthroplasty. Each morning, daily report begins with a review of the patients seen on call the prior day. Open fractures and other orthopaedic urgencies are usually taken care of by the call team, and the postoperative films for these patients are reviewed as well. The morning report is followed by a case presentation or topic review PowerPoint given by a resident. After the presentation is completed, the attendings make their way through the resident ranks pimping them on the subtleties of patient care not covered in the presentation. Conference is a tri-lingual affair, with the presentations and PowerPoint given in French, most of the discussion in native Khmer (Cambodian), and occasionally in English for my benefit.
After this, rounds commence. The entire team of trauma faculty, plus any plastics attendings available all make ward rounds together. There are tiers of rooms which the patients pay an additional cost per night for the perks of additional privacy and air-conditioning. The team starts with the “VIP” rooms where there is air-conditioning and 2-3 patients per room. The team shuffles through courtyards dotted with palms and other tropical trees. Eventually, the rounds progress to the second floor to the open air wards with 10-12 beds per room. The entire process is a controlled chaos, where attendings are having heated bedside debates, and will occasionally call residents, nurses, and other students into the rooms to comment on the care they have provided or simply to teach a salient point to the providers present.
As rounds are finishing, the residents will make their way to the operating rooms, where they are responsible for positioning, prepping, and draping the patient in time for the attending’s arrival. Depending on the nature of the case and the attending involved, the attendings’ role may be anything from a non-scrubbed observer (with the chief resident taking the role as surgeon and educator to the junior resident), to functioning as the primary surgeon with the rest of the team assisting.
The residents are quite skilled at the operative management of “bread and butter” trauma cases. The residents were insistent on making me the primary surgeon for all SIGN nail cases, because they were so interested in teaching, but also because they are so facile at the management of those injuries. Upper extremity injuries are usually treated with percutaneous pinning or non-locked internal fixation (from a piecemeal small fragment set). Closed lower extremity long bones are nailed using SIGN implants. Almost all of their open fractures are treated initially in external fixators, and often the elective cases for the day are to manage the resulting non-unions. There is often a significant delay (often greater than 7 days) between injury and operative intervention, in stark contrast to our typical operative approach in this country.
Kossamak Hospital does have an intra-operative fluoroscopic unit (donated by a hospital in Perth, Australia), but it is rarely used. The machine often breaks, there are no sterile covers, no trained techs to operate it, and only two lead aprons for a surgical team of 5-7 members. As such, the team does not wish to become too reliant on a technology that is still a luxury and often unavailable at their facility. The scheduled operative cases usually finish in the early afternoon, which frees the attendings to manage their private clinics. The residents then will either say at the hospital (if they are on call), head home, or most likely, head to a private clinic or call shift that they take to moonlight and make extra money.
While in Cambodia I had the weekend in the middle of my two week stay available for a trip to Siem Reap and the temple complexes at Angkor Wat and Angkor Thom. I spent the weekend exploring the ruins and taking as many pictures as I could manage. The weekend that I was leaving also happened to be a holiday weekend, a three-day celebration for the King of Cambodia. Again, I took advantage of the weekend off to enjoy exploring the capital city. As part of French Indochina, the city has portions that are heavily influenced by French colonial architecture, as seen in some of the buildings built at the turn of the 20th century along the river.
I am very thankful for the opportunity to take this trip. It was a phenomenal experience to see how an aid organization such as SIGN can have a long-lasting and meaningful relationship with a hospital in the developing world. I hope to be able to contribute in a similar way in my own career and forge a lasting relationship with hospitals and residency programs in the developing world. This trip was made entirely possible by the faculty in our department and I will be forever grateful for this opportunity.