Wednesday, September 5, 2018

Phnom Penh, Cambodia

Author: Chris Cosgrove, MD

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.

While in Cambodia, I also was able to use my first full weekend there to explore the city of Siem Reap. There is such amazing history behind the magnificent temples that were constructed by the Khmer Empire almost a millennium ago. I explored the ruins on a day long bicycle tour and learned a great deal about their ancient culture, traditions and the influences of various religions and kings over the centuries.

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.


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