Healing Wounds in Cambodia

Address correspondence to: Thomas E. Serena, MD, FACS The Serena Group 552 Quaker Hill Rd. Warren, PA 16365 E-mail: serena@healingwounds.com


   In 15 years as a general and vascular surgeon, I have witnessed unspeakable tragedy in the trauma room. Everything from having children die in my arms after suffering abuse from their parents to telling countless patients the dismal truth that they have incurable cancer, to wading through wound clinics across the United States. However, none of these experiences prepared me for Phnom Penh, Cambodia. The surgeon’s machismo that insulates him from the unavoidable suffering of his patients failed me shortly after arrival. Squalor and suffering in the hospital wards of Cambodia’s capital city is piercing. Landfills are populated by orphans. Land mines maim. Torture prisons, which are now museums, and the killing fields serve as reminders of the recent devastation brought on by the Khmer Rouge reign of terror. Yet, despite the sorrow, the Cambodian people remain resilient. Nurses and doctors are inspiring. As for me, the volunteer, I was a wide-eyed medical student anxious to ply the healing art. I left Phnom Penh vowing to return. I cannot thank the Association for the Advancement of Wound Care (AAWC) and Health Volunteers Oversees (HVO) enough for this opportunity.    Reports from volunteer trips inevitably read like National Geographic travel logs. As a long-time fan of such periodicals, I make no apologies. However, my goal is to introduce you to Cambodia, its remarkable people, war-torn past, and fledgling medical system. I will focus on clinical and educational challenges, the commonly encountered diseases, and the most pressing needs from a wound healing perspective.    Our team consisted of a physician and a nurse. Joe Meyers, long-time friend, business partner, registered nurse, ex-Marine, and Brooklyn native, handled nursing education and hands-on dressing demonstration. At more than 6 feet tall, he was the largest person in Phnom Penh. The combination of physician and nurse was well suited to paternalistic Cambodian society. After spending 3 hours with a group of nurses from a local Phnom Penh hospital, the head nurse delicately requested that we repeat the lecture for her physicians. “Doctors do not listen to nurses,” she whispered to me. I must have had a guilty look on my face because she quickly added, “Khmer doctors, I mean.” I had to admit that even though I practiced medicine in one of the most progressive countries in the world, I have on occasion failed to listen to suggestions from my nursing staff—and usually regretted it later. We made certain that the medical staff received the same instruction.    Our only cultural preparation for the trip was watching the movie The Killing Fields, starring Sam Waterson and Dr. Haing Ngor. Although the movie was graphic, the Hollywood version paled in comparison to the real life devastation of Phnom Penh. In the late 1970s, the Khmer Rouge executed all of the nurses, doctors, and anyone else with an education. In fact, wearing glasses alone could result in a trip to Toul Seng, a local high school converted to a torture prison. At lunch one day, the three nurse educators at Sihanhouk Center of Hope Hospital (SCOH) described how their families, most involved in medicine, were executed outside of the city in the killing fields. They had survived by leaving Phnom Penh with the rest of the population to work in the rice fields. One of them, Horn Hong, RN, accompanied Joe and me to the Killing Fields genocide memorial that afternoon. Today, bones of murdered men and decapitated women and children work their way up through the ground from shallow mass graves. I still awake early in the morning haunted by Hong’s personal account of this horror.    After several years of political stability, Cambodia is on the road to recovery. As a result, the hotels are filled with members of non-governmental organizations (NGOs) from all over the world. Our hotel, the two-star Goldiana, was no exception—I am not sure where either of the two stars came from. We met land mine removers, English teachers, adopting parents, and orphanage builders. A woman from Chicago invited us to visit her orphanage. It was a paradigm of education rivaling anything I have seen in the United States (Figure 1), but where did all of these orphans come from? This question led us on an excursion to the landfill: acres of garbage populated by more than 600 orphaned children who awake at 4:00 AM to collect recyclables. By the end of the day they can gather enough to buy a bowl of rice (Figure 2).    On our first day, we were greeted at 7:00 AM at the SCOH by more than 200 patients waiting in the 100˚ “winter” heat (Figure 3). It was impossible to see them all. If they were not seen that day, they returned the following one. The Center of Hope is a private hospital for the poor of Cambodia. Health Volunteers Overseas has partnered with SCOH to provide volunteers whose primary focus is education. In this role, we taught physicians and nurses through a variety of techniques: didactic lectures, hands-on teaching, rounding, attending wound clinics, and assisting in surgery. On an average day, we would give 4 or 5 didactic lectures to groups of doctors and or nurses (Figure 4). Flexibility of content in the lectures was essential. We modified the lectures to meet the needs of the group attending. One effective technique was to include pictures taken during morning rounds or from the wound clinic in the afternoon lectures. Most of the clinicians spoke English to some degree. However, there was a limit to the amount of material they could absorb in a lecture format. Therefore, we mixed the didactic presentations with a series of “hands-on” demonstrations. This was particularly useful in teaching negative pressure wound therapy ([NPWT], Figure 5). Daily rounds in the emergency room and surgical ward provided further learning opportunities. We also ran several outpatient wound clinics with the resident staff. Finally, assisting in surgery permitted us to teach limb-preserving procedures. The patient with the Wagner III diabetic ulceration was scheduled for an above-knee amputation (Figures 6 a, b, and c). We were able to perform a ray amputation followed by NPWT to salvage the limb. Assisting in surgery on this occasion was Dr. Christina Katarina Biller, Kat, a fourth year surgical resident from Temple University (Philadelphia, PA) who was spending her research year at SCOH. Kat provided the photos of the healed patient 6 weeks postoperatively. We are indebted to her for providing ongoing NPWT education after we left SCOH, as well as directing us to the only place in Phnom Penh that served American-style coffee.    The state-run Kossamak Hospital is dedicated to orthopedics, burns, and wounds. It lacked the resources of the SCOH (Figure 7), but not the dedication of the nursing and physician staff. Traumatic wounds are by far the most commonly encountered wounds in Phnom Penh. The primary form of transportation in the city is motorbike. Often, entire families ride on a single vehicle (Figure 8). There are few traffic laws and helmet use is sparse. As a result, we saw complex traumatic wounds frequently associated with compound fractures. The orthopedic surgeons performed heroic surgical repairs under less than optimal conditions, that is, without the use of fracture tables or fluoroscopy. The residual traumatic wounds, however, were frequently accompanied by significant soft tissue loss, contamination, and vascular compromise. Reconstruction would have been challenging under ideal circumstances. We introduced the nurses and surgeons to NPWT. Negative pressure allowed the surgical team to convert some of the more complicated wounds into simpler ones, which could then be closed with a simple flap or graft or even allowed to close secondarily. We are planning a NPWT conference for clinicians at the Phnom Penh hospitals, followed by a clinical trial at Kossamak. Thus far, Talley Group Ltd. (Hampshire, United Kingdom) has donated 6 NPWT pumps for this project (we certainly welcome further donations).    In addition to traumatic wounds, diabetic ulcers are common. Patients from the surrounding provinces typically seek care in Phnom Penh. It can take several days to reach the capital. Consequently, many of the diabetic wounds were complicated by extensive tissue loss and infection. Limb salvage techniques continue to be the primary focus of our educational efforts. There was a conspicuous absence of two types of wounds commonly seen elsewhere in the world—pressure and venous ulcerations. The paucity of pressure ulcers is a tribute to the frequent turning and repositioning performed by family members who are required to attend to hospitalized love ones. The venous leg ulcer (VLU) is the most common chronic wound worldwide. We did not see a single case in nearly 2 weeks in Cambodia. There is a historical explanation: the elderly population, typically afflicted by VLUs, was exterminated by the Khmer Rouge.    We visited several other hospitals and clinics in Phnom Penh. We witnessed unparalleled palliative care at an extended stay hospital for patients suffering from AIDS. It was suggested that there has been a reduction in AIDS cases in Cambodia. We were glad to see that the nurses at the chronic care facility had perfected the art of disinfection. The wards were petri dishes for infectious pathogens I had previously only read about in textbooks.    We discovered a quirky paradox in the Cambodian healthcare system that deserves mention. Despite strained resources and limited patient access to medical care, there is an over abundance of physicians. Apparently this is true throughout the developing world. The only plausible explanation came from a British Orthopedist and frequent volunteer at Kossamak Hospital, Dr. Dalton Boot. Dalton explained over a glass of gin in his flat a few blocks from Kossamak that there is an elite class in Cambodia. This was obvious. They drove black SUVs with Lexus or Range Rover emblazoned on the door panels—just in case you did not understand the hood ornament symbol. It was equally as obvious that the remainder of the population lives on less than a dollar a day. Dalton continued that parents in the upper class want their children to become doctors. Although the pay is only $60/month, it is considered a prestigious occupation. Hence, there is a physician surplus.    Future projects include negative pressure conferences and trials planned for later in 2008. There is an ongoing need for dressings, particularly antimicrobials. We are thankful to the companies that have already donated supplies (3M, Johnson & Johnson Wound Management Worldwide, Medline Industries, and Mölnlycke). In addition, physical modalities that do not require disposable parts are being explored, including hyperbaric oxygen and ultrasound.    Finally, I cannot resist recounting a few National Geographic moments. At the end of most days, we sat on the third floor of the Foreign Correspondents Club (featured in the Killing Fields), sharing our daily stories with the NGOs and foreign tourists who gathered to enjoy an Anchor beer overlooking the confluence of the Tonle Sap and the Me Kong Rivers. We ate spiders and slow-roasted cockroaches, rode Tuk Tuks (small carriages pulled by motorcycles) through death-defying intersections, visited the ancient Buddhist temples of Angkor Wat and Wat Phnom, walked barefoot on the pure silver floors of the aptly named Silver Pagoda, cheered on kickboxers, haggled over silk scarves in the Russian market, cruised out to the floating city in Lake Tonle Sap, gained a rudimentary grasp of an Eastern tonal language through total immersion, and survived Dengue Fever—actually Joe survived Dengue. I made the diagnosis of the “bone-crusher” while he was sprawled across the couch at the Goldiana waiting for the driver to take us to the airport.    Recently, the World Health Organization (WHO) has made a commitment to developing wound care protocols for use in programs across the world. The HVO, in conjunction with the AAWC, has already established several sites actively recruiting volunteers. Please consider joining the HVO and getting involved.