Return to Canada & Trip Highlights

After a 26 hour trip we made it safely back to Canada. We flew from Phnom Penh to Seoul Korea and then 13 hours direct from Korea to Toronto. It was in Toronto that we had to part ways- Mary was flying back to Calgary Alberta and Cathy back to Ottawa, Ontario.

It was hard to part at the Toronto airport after having gone through so many experiences. We were both thankful to have had the opportunity to participate and our hope if for others who have a interest to get involved in volunteering to make a difference in the many lives all over the world that are impacted by wounds.

Mary and Cathy say good-bye at the Toronto Airport after 26 hours of travelling

                 
                    



Thank you to Health Volunteers Overseas:
Mary & Cathy at the Sihanouk Hospital Center for Hope -
Please consider volunteering to support global wound management

In additon to the wound management volunteering we were able to work in the following which were highlights of our trip:


We feel very fortunate that we were able to visit the ruins of Angkor Wat in Siem Riep after taking a 6 hour bus ride on the Mekong Express

We were able to visit the ruins of Angkor Tom in Siem Riep

We took a Cambodian cooking class



We made a visit to the Royal Palace in Phnom Penh

We saw the Killing Fields from the days of the Khmer Rouge - this was very sad

                         

The Mobile Clinic

We had the opportunity to go to visit a mobile health clinic run by the Sihanouk Hospital that was located 45 minutes outside of Phnom Penh after we received an invitation from the Manager of International Volunteers from the Sihanouk Hospital center for Hope-Sideth. We met him early morning in front of the hospital and he took us in a SUV with a driver to an area outside of the city where very poor people of Phnom Penh had been relocated by the government. These people were moved to an area where they were given the opportunity to live in a "shack" like home which was provided for them by the government. Once the community was set up, a mobile health clinic was put into place to assist with the health needs o the people. Due to the distance from Phnom Penh, many of the people had no jobs or little source of income and lived in a state of poverty.

 Cathy & Mary greet children near the mobile clinic

                                                                                  
When we drove up to this community we were struck by the poverty that we witnessed. The homes were made of crude materials - open to the outside with no glass windows, very small in size often housing more than one family in a very small space. There was no electricity, running water or plumbing in the homes. Holes were dug behind the homes to serve as a toilet creating a mecca for unsanitary conditions. Small children walked around without diapers which were too costly. The children in the community started to follow us around calling out to us "hello" "hello" which was the only word that they could say in English. We spoke with them and played with them.

Doctor inside the mobile clinic

We went into the clinic which was made up of a general waiting room with a roof- no windows and open to the air - and a one room clinic- no exam room - everything was open. There were two doctors, two nurses and a room full of people waiting to be seen. There were several cases of tuberculosis, diabetes, children's coughs and colds and diarrhea. The people came in one at a time or a child with their mother to be seen by the physician. We noticed very simple teaching charts on the wall. One wall chart demonstrated why a child should wear shows to protect their feet. Not one of the children that we saw were wearing shoes. Another chart demonstrated the need for mosquito nets as Dengue fever is a big problem from mosquitos in this area. We were told that sometimes when a family receives a mosquito net, they use it for a fishing net and not the intended purpose.
We were also taken to see a set of two row houses that had been built by Habitat for Humanity. They were located about a ten minute drive from the mobile clinic. In order to live in one of these houses, the people had to pay $15 dollars per month. These houses were better constructed, had a toilet and access to clean water. One of the residents took us for a tour of their little home. It had a small bedroom, small living room, very small kitchen which was partly outdoors with a roof over it and a small bathroom.

After seeing the state that these people live in, our hope is that everyone should realize how fortunate we are to have a roof over our heads with reasonable space to live in, clean drinking water and clean clothes to wear.

Unexpected Request for Wound Consultation at CRC Surgical center

We were asked by a surgeon at Kossamack if we would call a physician who ran a clinic and surgical center in Phnom Penh.  He said that this physician had quite a few patients with wounds as well as a recent victim of an acid attack who was badly wounded.

We said that we would assist this physician any way we could and we arranged to meet him at his clinic in the early afternoon. he took us by SUV to the CRC Surgical center which was on the out skirts of Phnom Penh. We walked into a building which had a reception area that was filled with Surgeons and nurses. We were ushered down a thin hallway were several patients sat lined up against the wall. When we rounded the corner we were shocked to see a large room packed wall to wall with patients lying on beds - there were at least 70 people. The room had a strong odour of unwashed people in a temperature of about 90 degrees (no air conditioning)

We were introduced to the Nursing Director and the nursing staff who were instructed to initiate a wound clinic at the end of the recovery room. The scene was as follows- patients were coming back from the Operating Room to be recovered from anaesthesia and right beside them a wound clinic was going on because there was no other space to hold it.



We saw 11 wounded patients in the next 3 hours with some atypical wounds. There were two patients who had tuberculosis in their spinal cords who had post op spinal incisions due to recent surgery. There was a 17 year old boy who was bitten by a poisonous snake and went into a coma.  He ended up with a stage 3 pressure ulcer on his sacrum secondary to the snake bite and lying in one place. We saw a young boy with a third degree burn to his foot- several weeks post skin graft. We saw a post op head incision from a brain aneurysm repair.

And then we met the woman who was a victim of an acid attack. (see separate entry on acid attacks)

Kossamak Hospital

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)

Teaching Wound Care in Cambodia

We had the opportunity to teach wound care at both the Sihanouk Hospital Center for Hope and the Kossamack Hospital in Phnom Penh. We did an assessment of learning needs before we put together a "Wound Care Primer". Cathy taught the anatomy and physiology of the skin, phases of healing, type of healing and cellular response.

Cathy Teaching anatomy and physiology of the skin

Mary taught acute and chronic wound assessment, infection vs colonization, wound measurement and proper swabbing technique.

Mary teaches wound management

Mary also taught negative pressure wound therapy rationale and application technique. All the health care staff that we met here in Phnom Penh are very interested in NPWT (VAC). We were told the VAC dressing were originally brought by a physician 4 years ago and they continue to get supplies donated by many individuals and sources. Sihanouk had VAC dressings available to them including Versa foam, but no working pump.   They use Gomco suction and it is quite effective.  Kossamack Hospital was a different story.  They had the granufoam and that was about it.  They use plastic wrap, packaging tape and a suction tube.  This is connected to a fish tank pump and large glass suction container.  They are presently trying to source a sponge that is similar to the granufoam that will be effective to use for NPWT.  Their biggest challenge is sterilizing the sponges they source in the market that don't disintegrate in the high heat.

Mary teaches Negative Pressure Wound Therapy by Papyra

In order for Mary to provide hands on experience and demonstrate the application of the VAC, we were able to get a Papaya (largest fruit here) and we simulated a wound by cutting out the flesh of the fruit.  This turned out to be a very effective teaching tool because we found that the language barrier was more of an obstacle than we expected and that pictures and hands on learning was much more effective in teaching.  Mary demonstrated the VAC application and procedure, but soon realized that this was a learning moment for her as she had never used plastic wrap, packing tape and suction tube connected to a fish tank pump.  We were amazed that when all was done, a seal was attained and the sponge sucked down beautifully.  It was a wonderful teaching moment for all involved!

Mary teaching application of NPWT on a papyra

We had more senior nurses attend our educational session at the Sihanouk but were amazed to have 30 Nursing students, 4 staff nurses and the head surgeon attend at Kossamack.
As mentioned previously, we had to speak very slowly and use pictures as a frame of reference due to the language barrier. We also had to stop frequently to ask for translation on certain sections that we could tell the group was not understanding. We received very positive feedback from both groups - they seemed to grasp our concepts.  We in turned were thrilled to be able to share our knowledge while integrating their supplies and overcoming the obstacles of being countries apart, yet all dealing with the same goal....effective wound care.

Cathy teaching Nurse Educators  wound care

ACID ATTACKS: The CSC Surgical Center : Phnom Penh

We had been asked by a HVO Orthopedic Surgeon if we could go and see a wounded patient who was at the CSC. The CSC is a hospital run by a British Physician who also oversees a clinic. We were told that there was a woman who had been a victim of acid attack. Today we met the female victim of an acid attack who was one month post attack.

We were told that this 54 year old lady worked for the community and that she had spoken too some young men about the careless riding of their motor cycles as she was concerned about the safety of the people. The young men were angered and attacked her with acid.

When the woman was brought into the treatment room we were saddened by her bandaged body and her difficult physical situation and  the pain of her suffering.She had lost one eye completly and her second eye was sown shut. The nurses told us that the lady said she could see some light out of the eye that she had left. Her nose had been burned off and she sustained third degree burns to her head, face, neck chest and arms. She had a large wound on her head due to infection and debridement. She is married with children.  She had been in the CSC for a month and she was expected to stay another. Her attacker was caught and will go to court.  Jail terms depend on the severity of the attack and disfigurement.

 Background on acid attacks:

At least 44 acid attacks were reported in Cambodia in a three year period up to November 2002,

injuring 60 people and killing three others. This means an average of one attack every 25 days.

These statistics from newspaper reports, and the real number of acid attacks may be higher. Not all cases may be reported in newspapers.

Nearly one third of the people injured in acid attacks are not the intended victims. This is because acid is a messy weapon, and other people nearby the victim at the time of the attack are often injured accidentally as well. For example, two young boys were badly injured in an acid attack which killed their mother. In another case, a woman threw acid at her husband but it also hit her own 5-year-old son.

The targets of acid attacks are mainly women, but men are also deliberately attacked. Both men

and women commit acid attacks.Most attacks are perpetrated because of family or personal relationship disputes or problems.

The most common types of attacks are:       

1) Wives throwing acid against their husbands’ mistresses or second wives: to take revenge

and destroy the appearance of the victims so tha t the husbands will not stay w ith them;

2) Husbands throwing acid against their w ives or former wives: usually to punish them for some alleged mistake or because of jealousy or anger about a se paration or divorce.

3) A less common but especially disturbing type of attack is women who throw acid at their

husbands because the husbands beat and abused them. This shows what can happen when domestic violence is not stopped, and victims feel they have no other way to protect themselves.

4) Acid throwing highlights serious problems in Cambodian society and families. The root causes

of acid attacks include high levels of violence and social problems within society, and widespread discrimination against women.

Decades of war, genocide and poverty have damaged the morals, Buddhist principles and family

values of people and created much violence and crime in society. Many people use violence as a

way to settle problems or disputes. Violence is common within families, as well a s social problems

such as alcoholism, marital quarrels and infidelity. Some men abuse their wives or take mistresses or second wives. Women have little power to stop misconduct by their husbands or get justice for it. In these circumstances, people resort to throwing acid, r ather than peacef ul and lawful means, to

express their jealousy and anger or to try to re solve their problems.

Women are often the targets of acid attacks, which indicates that society often blames women –

rather than men – for family problems. Even women perpetrators may blame other women,

rather than the men who are involved. For example, an angry wife is far more likely to throw

acid at her husband’s mistress than at her unfaithful husband.

Other factors contribute to acid attacks, including that acid is a cheap and easy weapon to obtain

and use, compared to guns, knives and grenades. Another problem is Cambodia’s weak police

and court system, which is corrupt, ineffective and poorly resourced. Acid throwers and other

criminals may be able to avoid justice, especially if they are richer or more powerful than their

victims. If perpetrators are not punished, it encourages other people to think that they can commit the same crimes with impunity.

Without strong action against acid throwers, the number of cases will probably increase and the

reasons for attacks will grow more varied. Already, it is not only family problems which lead to

acid attacks. In a few cases, other reasons for attacks have included robbery or personal quarrels

and disputes not related to family matters. Hospital doctors say they have also seen some cases

related to land or property disputes.

Acid throwers mainly use sulfuric or nitric acid, which are two of the strongest acids and can eat

through the skin, muscle and even bones of humans.Sulfuric acid is very common because it is used in car and motorcycle batteries. Battery acid is heavily diluted, so that it is 75-80% water, and weaker and slower to burn it if touches human skin. Acid throwers prefer stronger, undiluted sulfuric acid. Undiluted sulfuric acid sells in Phnom Penh for about 3,000 riels a liter, and diluted battery acid for 500-600 riels per liter.

Acid burns are among the worst injuries that a human being can suffer. Victims’ faces and

bodies are tortured by the acid, leaving them with hideous scars and disabilities for the rest of

their lives. Blindness or deafness may also occur, because the acid is usually thrown at the head.

Victims who survive their injuries have a long, painful and exhausting recovery. Deep burns are

very difficult to heal and vulnerable to infection and other problems. Victims usually have to

spend weeks or months in hospital, until their wounds begin to heal and the risk of infection is

gone. Most will need multiple surgical operations and treatment lasting for years. Medical expertise and equipment is poor in Cambodia, and severe acid damage can never be fully repaired. Acid victims will never look the same as they did before. Victims often have to pay for their medical treatment, and the quality of treatment they receive may depend on how much money they have. Some victims may not go to hospital at all, but try to treat their own wounds or go to local medical clinics or traditional healers.

Acid burns through skin and flesh layer by layer, causing great pain and injury. It eats through

the two layers of the skin, into the fat and muscle underneath, and sometimes down to the bone.

It may dissolve the bone. The deepness of injury depends on the strength of the acid and the

duration of contact with the skin – the burning continues until the acid is thoroughly washed off

with water.Thrown on a person’s face, acid rapidly eats into eyes, ears, nose and mouth. The pain is

excruciating, as an intense burning heat cuts through the victim’s flesh like a hot knife. Eyelids

and lips may burn off completely. The nose may melt, closing the nostrils, and ears shrivel up.

Acid can quickly destroy the eyes, blinding the victim. Skin and bone on the skull, forehead,

cheeks and chin may dissolve. As well as the face, the acid usually splashes or drips over the

neck, chest, back, arms or legs, burning anywhere it touches.

The biggest immediate danger for victims is breathing failure. Inhalation of acid vapors can

create breathing problems in two ways: by causing a poisonous reaction in the lungs or by swelling the neck, which constricts the airway and strangles the victim. One Cambodian acid victim died because the acid flowed into his nose and airway. But victims usually do not die. The aim of most acid attacks is not to kill, but to maim and disfigure. The perpetrator wants the victim to live with a mutilated face, looking like a monster, and continue to suffer forever.

Source: Cambodian League for the Promotion & Defense of Human Rights (LICADHO)

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Another great day at the Sihanouk Hospital Center for Hope

We found the hospital library and met with the librarian. We were impressed at the extensive collection of medical/nursing/healthcare text books they had. We donated 5 text books on wound management (thanks to our colleague Virginia McNaughton who dropped them off the night before we left) copies of the JWOCN, the CAET Link, Wounds, Ostomy Wound Management and Wound Care Canada. We recommended that there be a designated section set up in the library for wound care books, journals and literature which he agreed to do. We were very pleased that we were able to assist in setting this wound care section up. For those of you who have medical/nursing  text books that you want to pass on, this library would be a good place to consider donating them to. We can arrange it for you.

The Hospital Library at the Sihanouk Hospital Center for Hope

                             
We went over the the surgical clinic to contribute to a VAC application on a patient with a large wound as a result of an abcess. The abcess had been drained but the wound was large, infected and was showing few signs of healing.When we arrived we were told that we would have to go to the Operating Room because the procedure would be done there due to the patient experiencing pain and the need for surgical debridement. We quickly got ready for the OR and joined the two surgeons.

Cathy and Mary in the Operating Room

A HVO volunteer collegue Raymond who is a nurse anaethetist was also in the OR theater for the case teaching anaesthesia administration  Mary provided the surgeons with her strong expertise on the aplication of VAC Dressings. The wound was very deep and it required layering of the sponge. Mary guided the surgeon in the proper technnique in layering the sponge.

We provided an eductional presentation to  about 8 nurses and nurse educators on the basics of wound care, including the anatomy of the skin, phases and principles of wound healing. We covered the technique of wound swabbing and the lights went on. We will continue this later.