We were invited to visit and give an educational presentation at Kossamak Hospital by an orthopedic surgeon from Anchorage Alaska, Dr. Tom Vassileff. He was visiting Phenom Penh with his wife to do volunteer work for Health Volunteers Oversees. He had heard there were a couple of "Canadian Wound Care Nurses" in town and tracked us down to come to this hospital. We arrived in the morning in time for rounds with the surgeons and nurses. Discussion ensued regarding certain patients and Xrays were reviewed. The room for rounds was open air, a ceiling fan and it was very hot.
After approximately 45 minutes, we set off with the group to do rounds to see patients. We went from room to room, each consisted of approximately 8 - 10 beds, all occupied by patients. The rooms are open to air. There are no windows and screens and only shutters to protect them from the rain. It was hot, humid and there was an odour that you get when numerous people are confined to a small space. Most of the patients are charged for thier care by a sliding scale for payment of treatment. What they can afford they pay. There are 10 beds reserved for patients who can not pay. We met a young girl who had an above knee leg amputation because of a tumour and a 13 year old boy who had unknowingly picked up landmine and lost his left hand and partially lost his right hand. His mother was by his side and the boy looked dispondent. Family are expected to stay with patients to provide care and to cook for them. There was a young man who had been electrocuted and lost his left hand. His wife cried silently by his bedside and when she saw Cathy, showed her 2 dollar bills to indicate she did not know how she was going to support her family now that her husband can no longer work. There was a young boy who was attacked by a man with a chain saw and had a cut down the center of his face. There was an older woman with amputated toes due to diabetes. We were told that there is a high rate of Type 2 diabetes in Cambodia even though obesity is not a problem. Rice is the staple of a Cambodian diet and they do not get much excercise. We were told this may be the cause.
As we moved from room to room, it became evident that moto accidents are a major cause for hospitalization and surgery. We were not surprised as we had now spent approximately a week on the roads of Phnom Penh and many times we had to squelch a scream as we were sure we were going to be hit. It was actually this very day that our Tuk Tuk driver hit a couple on a moto and they fell over. There was very little speed involved and fortunately, the two picked themselves up, got on the bike and drove away. This was our first moto accident in Phnom Penh! Many patients have fractured legs and external fixation devices are used.
|Orthopedic Trauma resulting from a Moto accident|
After patient rounds we followed the nurses around to do wound care rounds. They had metal dressing carts that consisted of garbage on one side, a large metal container with a top that was full of sterilized gauze and a drawer that contained many metal boxes with lids that turned out to be dressing trays. There was a bowl with cleaning solution for instruments. They use scissors to cut bandages and clamps to hold the gauze when they clean wounds and incisions. They went from patient to patient to do wound care and incisional care. There technique was lacking with some of the nurses cleaning wounds from dirty to clean. We corrected their technique through the use of an nurse from Sihanouk hospital who acted as an interpreter. Overall their technique was very good. The dressing that are used are gauze, cling, vaseline impregnated gauze and betadine. They make their own vaseline gauze using petrolatum jelly and gauze bought from the market and then sterilized in an autoclave.
|Mobile wound dressing change cart - sterile gauze is kept in the silver container on the top of the cart|
What was very difficult to experience was the pain endured by the patients and intensified by the dressing change. The contortions on their faces said it all. We were told that the government stopped providing pain medication to patients and the pharmacy lacked stock. Patients and their families are unable to afford to buy pain medication. Occassionally the hospital receives some codeine but this is sporadic. We tried to distract a patient who had surgery the day before on his elbow by taking his picture and showing the results on the camera. This seemed to help a little and it was the least we could do in a difficult situation. It was interesting that we observed the pain on the patient's face but there was relative quiet in the room. Cambodians are very quiet people and they suffer in silence.
|Student Nurses learning the principles and technique of wound dressing changes on orthopedic trauma patients|
|Mary & Cathy with all of the nursing staff and the chief of surgery|
We continued on to our educational session (please refer to teaching blog)