Through the generous support of the Orthopaedic Department
at Washington University in St. Louis, I was able to spend two weeks visiting
Phnom Penh, Cambodia at Preah Kossamak Hospital. I arrived in Cambodia’s
capital, and largest city, on a weekend which provided me the opportunity to do
some city exploring right away. This was extremely important, as understanding
the history of this country established the lens through which I would be able
to frame all of the subsequent experiences during my trip. Phnom Penh is a busy
city of over 2 million people and lies at the confluence of the Tonle Sap and
Mekong Rivers. Though the city skyline is full of high-rise buildings under
construction, a closer look at the city streets reveal the truly impoverished
state shared by a many of its citizens. The country is still recovering from
the enormous void left by the Khmer Rouge war in the mid-1970s and their
attempted destruction of the country’s socioeconomic, political and religious
institutions, along with the terrible genocide of millions of Cambodia’s
citizens. My city tour through the Killing Fields, S-21 Genocide Museum and
Royal Palace took me back in time and gave me new insight into the lives of the
patients whom I would be seeing the upcoming week at Kossamak.
My contact with Dr. Duong Bunn, their department chair at
Kossamak, was through the SIGN International organization. This group supplies
hospitals around the world with a unique brand of intramedullary nails that do
not require intraoperative fluoroscopy, utilizing an aiming arm for both
proximal and distal interlocking screws. Kossmak, which is a public hospital
that primarily deals with uninsured trauma patients who come from both the city
and from surrounding provinces. Kossmak is the world’s largest user of the SIGN
nail – averaging just over 90 nails per month! The use of this device over the
past 15 years has dramatically changed the quality of care provided to their patients,
who are largely unable to afford any aspect of their medical care. Their trauma
is largely fueled by the wildly chaotic driving conditions around the city.
Traffic laws are more like traffic suggestions, and the only true rule of the
road that everyone seems to share is to drive as quickly as possible and try
your best not to get hit. People on motorcycles and rickshaws zip in between
cars, through intersections and against traffic. They also see a substantial
number of patients with delayed presentations of open fractures, chronic joint
dislocations and other unique pathologies after seeking care by their local
town ‘healer’ for a period of time.
The residents were very welcoming and excited to include me
in on cases. Their residency experience shares many similarities with ours.
Each morning starts with a fracture conference where cases that were done
overnight were presented, followed by a short PowerPoint didactic lecture given
by one of the junior residents. After the morning conference, the attendings
and residents all go on group rounds together. It continued to amaze me how so
many patients and their families were able to crowd into small rooms. Patients
lied on rusty stretchers while their family sat on the floor next to them with
only natural lighting, exposed to the outside air and construction. Family
members would hand radiographs to the attending to remind them of the injury. Family
also functioned as the dining service (there was no hospital cafeteria),
physical therapist and wound care nurse while their loved one was in the
hospital. It was truly impressive to see.
The majority of their residency experience revolves around
the trauma they take care of at Kossamak, although residents are able to do
short rotations at other private hospitals around the city where they can have exposure
to pediatrics, arthroscopy and arthroplasty.
They take Q3 call while at Kossamak and often do cases through the
night. Most open fractures are taken immediately to the OR and placed into
external fixators, as there is no efficient medical transportation to get the
patients to Kossamak in a timely fashion. The patients then have to wait for a
variable amount of time (sometimes over a week!) for their definitive care.
I was incredibly impressed by the operative skill of their
residents and attendings. They did the best work they could with the limited
tools available to them. Everything that could feasibly be K-wired together,
was K-wired. Without the use of fluoroscopy, most fractures were opened and
reduced with wide exposures. Fractures that needed internal fixation with
plates and screws were subject to variable quantities of different sizes and
types, mixed and matched to come up with a construct that would be up to the
task. Most screws had to be cut to the appropriate length. I admired the
temperament and commitment of the faculty and residents there to provide the
best care possible despite the conditions in which they worked. No one bothered
grumbling about their lack of instrumentation, poor lighting, the preponderance
of flies in the OR, or the innumerable other conditions that would drive
surgeons in the United States to immediate retirement. Despite being acutely
aware of the limitations imposed upon them, they rolled with the punches and
found creative ways to make things work. Time and time again.
I am so thankful that the Washington University Orthopaedic
Department continues to afford us this once in a lifetime opportunity. The
transformative experience truly has impacted me in ways that I never imagined
possible. I left with a new appreciation for the trauma care we’re able to provide
in the United States. I left with a profound gratitude for our orthopaedic
training, but also an admiration of the shared altruism and motivation to help
heal patients, regardless of circumstance. I also left with motivation to get
involved with philanthropic organizations like SIGN International to assist
developing nations like Cambodia take care of their injured citizens, who so
desperately need to function to provide financial stability for their
struggling families. I cannot express how appreciative I am for this
experience.