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.

          

Farewell to Dr Monica Joyner, Plastic Surgeon

Dr Monica Joyner, Mary, Cathy & Dr J Bleicher at Radang

Sunday night we had to say farewell to Dr Monica Joyner who was returning to Indiana, USA after a week in Phnom Penh. We were sorry to see her leave as we really enjoyed getting to know her. We welcomed a new Plastic Surgeon, Dr Joel Bleicher from Iowa, USA. The four of us had dinner together before Monica's departure at a restaurant called Radang which is a place where Cambodian street kids are trained in the restaurant industry. Monica- we wish you all of the very best and hope that our paths will cross again some day. You are truly an amazing and inspirational woman.

HIV Service and the Warehouse at Sihanouk

We were at the Sihanouk Hospital Center of Hope for another interesting day. We started off by meeting with the manager of International Volunteers named Sideth and the Hospital administrator, Dr. Gerlinda Lucas, a Medical Doctor from the Phillippines who had experience in Hospital Administration from working in Hope Worldwide Hospitals in Afghanistan and Russia. She was very impressive with her knowledge of operating a hospital system and she had very strong objectives around keeping the hospital in operation until funding kicked back in January 2012.

We were taken by Sideth to the department of nursing education where we were introduced to Mr. Horn Hong (known as Hong). He is in charge of nursing education for the hospital. We spent some time with Hong learning about the educational needs for wound care and he booked us to do two lectures to the nurses- one on Tuesday and one on Thursday.

Cathy and Mary with Mr. Horn Hong, Nurse Educator

                                    
Hong first took us to meet a nurse who works in the HIV clinic. One important service the hospital offers is the availability of life-prolonging antiretroviral drugs (ART) for patients living with HIV/AIDS. More than 2,800 HIV positive patients are currently being treated by the hospital. We saw many young men and women attending this clinic. Several young women looked to be in the end stage of the disease and were given beds to lay down on, oxygen masks were in place and their sweet little children sat beside them on the bed. This was heart breaking. The nurse from this clinic will take us to the city hospital on Thursday with a reconstructive surgeon.

Hong then took us on a tour of the Warehouse to view the donated supplies sent by charities. There were several large boxes of medical device materials that had just come in and we worked with Hong and the warehouse staff to sort through the supplies, pull out the wound care dressings and supplies, and identify as many of the medical devices as possible. We were struck by the fact that while it is essential for this hospital to receive supplies, the supplies were sent all mixed together and spread in the box. There were no labels indicating what the products did and it was apparent that the staff did not know what many of the products were used for due to the language barrier and the lack of wound product knowledge.

They took us over to the shelving area where they had very neatly categorized and placed boxes of wound care supplies. Again, there was a similar situation that while they had boxes of some wound care dressings, they were not sure as to how they would be used. We went through many of the supplies and reviewed the indications for use and Hong took notes for follow up. We discovered products for continence care (two step cleanser and skin protectant). We instructed Hong as to how they could use these products. It became blatantly clear to us that there is a disconnect between the warehouse and the surgical clinics regarding products.  The warehouse staff are unaware of the products types and usages and the staff in the clinics are therefore unaware of what they have available to them. We hope we can somehow narrow the knowledge gap here.

We found boxes of mixed medical supplies from charities

                               
We then saw several boxes of ostomy products that were all mixed up between four large boxes. There were products which had been donated representing all main ostomy company brands. None of the boxes were organized and there was a lack of understanding as to where and how these ostomy products would be used and applied. We offered to come and organize and label the ostomy products by type of ostomy , size and coordinating products. We will also develop a "Product Selection Tool" for the use at this Cambodian hospital.
We were then introduced to the Surgical Charge Nurse, Sam Oeun and she gave us more information on nursing care of wounds. We had the opportunity to see one of the staff nurses change the dressings on a woman who had been in a moto accident and sustained an acute , traumatic wound to her left knee.  Much attention is given to sterile procedure and technique when doing dressing change due to many patients have multi resistant bacteria.  Surgical patients are put in isolation when they come to the surgical clinic and wound swabbing identifies many with resistant organisms.  MRSA, VRSA, EBSL is rampid here mostly due to the fact that antibiotics in Cambodia can be bought in the local drug store with no prescription and people self medicate at a very early age. Isolation rooms are identified  with a sign taped to the door. Sam Oeun told us that they always wash there hands when they leave the room, but when we inquired if they washed their hands upon entering she said they do not. We reviewed the principles of handwashing with Sam Oeun - "wash in and wash out". We explained that resistant bacteria is on everything including chairs in the waiting room, IV poles and other equipment.  Infection control techniques, or lack of them was identified to us by Dr. Haerner as a huge problem in the clinics. What is also interesting was we noticed most nurses wear masks all the time (the same mask through out the day).  Hong told us that this started during the H1N1 outbreak last year when they heard on the news they should wear masks.  Of course, they are wearing the wrong masks and do little to protect them from the transmission of bacteria or virus, but education to get them to stop wearing them has been futile.  Because there is a shortage of these masks they wear them all day from one patient to the next, unknowingly putting themselves at risk and their patients.

Sam Oeun explained to us the many wound care cases they see in the clinic.  It is typical for woman in the country side to care for their wounds.   For woman who have fungating breast wounds due to breast cancer the typical treatment for odor control is to crush charcoal and apply it directly to the wound. They continue to do this everyday until there is a thick crust of charcoal over the breast.  If and when they seek treatment at the clinic, the staff are unable to remove this adherent charcoal crusting and they perform a mastectomy.  She said many of these woman are young.

Cleansing solutions used in the clinic are a mixture of 3 teaspoons each of Hydrogen Peroxide, bleach and vinegar in 1 litre of Normal Saline.  This solution is used to clean infected wounds.  Betadine is mixed in water in a bowl to soak infected/dirty foot wounds.  Hydrogen Peroxide and normal saline are used in the OR to irrigate and  cleanse wounds.   Honey from the country side is used on wounds and they find it very effective in healing.  Any honey is used and usually bought in the local market.  Gauze is also bought in the local market for the clinic and sterilized in the autoclave.

The temperature outside was extremely oppressive. Shade and clean drinking water are needed by everyone. We are preparing for our wound care lecture tomorrow.

Happy Canadian Thanksgiving from Phnom Penh

We would like to wish all of our family and friends a very Happy Thanksgiving. We want to share some of the delectable food from a Phnom Penh night vendor - a very interesting Thanksgiving feast.

Mmmm, snake kebabs!

Not a snake person?   There were a wide variety of bugs to choose from!

The cockroaches were very crunchy!  (and in case you were wondering......they don't taste like chicken)

Love from Mary and Cathy

The Sihanouk Hospital Center of Hope, Phnom Penh

Our Introduction to the Sihanouk Hospital Center of HOPE
The Sihanouk Hospital Center of HOPE, has been open since 1996, and  provides a center for education and clinical training of medical professionals, while providing 24-hour health care to thousands of medically underserved people at no charge.The hospital is staffed with nearly 400 people, the majority of which are Cambodian and have received medical training at the hospital. The hospital, managed by HOPE worldwide, is one of the busiest in the country and sees 350 patients daily and more than a million patient consultations have been completed since 1996. One important service the hospital offers is the availability of life-prolonging antiretroviral drugs (ART) for patients living with HIV/AIDS. More than 2,800 HIV positive patients are currently being treated by the hospital.

Patients enter the hospital system through the Outpatient Clinic or Emergency Room. The medical and nursing staffs manage the majority of patients since only the most serious are admitted to the medical ward. The hospital is a member of MEDICAM, the membership organization for Non Government Organizations (NGOs) active in the health sector of Cambodia.

Across the street from the Sihanouk Hospital Center of HOPE is a for-profit Medical/Surgical Clinic.Patients who come to this clinic must pay privately for their medical or surgical service under three levels of payment which were termed as Level A, Level B and Level C which is based on income.

The driver from Sihanouk picked us up at 0800 and took us to the main campus. We went up to the International Volunteers office and a manager escorted us to the department of Nursing Education. We met a Nurse Educator by the name of Hay who welcomed us to the hospital. She was involved in wound care and she offered to take us over to the Medical/Surgical Center to see some patients who had been admitted with wounds.

Dr Monica Joyner and Cathy outside the hospital

Sign in Hospital Foyer

We walked across the street to the clinic and it was very hot. A guard was outside the clinic door monitoring the people who entered and left the clinic. We went up to the Surgical Center and it was full of activity. We learned about a young girl who had sustained a large acute traumatic wound to the outside of her knee ad leg as a result of a tractor collapsing on it. Dr Joyner and Cathy went into the operating room where a Cambodian Orthopedic surgeon performed surgery to drain infection as well as do a skin graft. He took skin from her thigh and grafted the wound very carefully. Once the skin graft was sutured into place he immobilized the leg using casting material , bandaged with gauze and wrapped the leg and instructed the bandages to be left in place for five days before changing.Resources are very precious and so every bandage was placed with care - and there was certainly no waste.The operating room team worked very efficiently together. We will follow up with this patient after the weekend.

Treatment Room in Surgical Clinic

Cathy, Ready for the OR

While we were in the operating room, Mary was shown around the surgical floor by nurse Hay. They have 6 rooms and seven beds.  One room is for VIP (very important people aka people with money). One isolation room with a young girl of 16 years who broke her leg in a moto accident (very common here in Phnom Penh).  She had an external fixation device and a leg wound that had just closed.  She was MRSA positive which is also very common as they have trouble controlling the spread of it in the surgical area because of the close proximity of patients and the less than adequate infection control techniques. 

Mary and Surgical Clinic Nurse outside the clinic

Once Cathy and Dr. Joyner returned from the OR we met with Dr. Cornelia Haerner, a general surgeon who has dedicated her service to the Surgical Centre and the Centre of Hope for 12 years.  We were able to observe minor surgery on a gentleman who originally had an abdominal abcess, resulting in septicemia, ICU stay and ultimately an open abdominal wound. Dr. Haerner had previously attempted to close the defect with a mesh and had success for a short time before it reopened again.  Today she removed a small amount of scar tissue proximal to the wound and the sutures beneath it which was the cause.  She sutured the area closed.  To dress the wound a 4x4 gauze was laid over it and a sugar solution poured over top.  More gauze was used as a secondary dressing and tape.  The sugar solution is made at the hospital by the nurses.  It consists of boiling 1 litre of water and then letting it cool to a warm temperature.  1 kilo of sugar is then added to the water and dissolved.  More sugar is added until the appropriate viscosity is achieved.  It is stored in what looks like a clear 500 ml saline container and used with no expiration date.  We were told the sugar solution for wound care is effective in controlling bacteria due to its high osmolarity.  We found this very fascinating and somewhat perplexing, considering it is a sugar solution that is left at room temperature and used on wounds to the last drop.  We wondered about bacteria growth in the bottle but we were assured that the osmolarity of the solution killed the bacteria.  It was then we realized that all our knowledge regarding advanced wound care products would have to be suspended because they have very little technology and supplies to work with and our knowledge of wound assessment and infection control would be shared with our colleagues here in Cambodia.  Dr Haerner recommended that we keep things very basic.

The Leprosy Hospital - Kein Khleang Center

The Horror of Leprosy

More than 213 000 people mainly in Asia and Africa are infected with Leprosy, with approximately 249 000 new cases reported in 2008.

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, an acid-fast, rod-shaped bacillus. Leprosy impacts the skin, the peripheral nerves, mucosa of the upper respiratory tract and also the eyes.Leprosy manifests with a skin lesion - single or multiple, usually less pigmented than the surrounding normal skin. Sometimes the lesion is reddish or copper-coloured. A variety of skin lesions may be seen but macules (flat), papules (raised), or nodules are common and with definite sensory loss, with or without thickened nerves. Leprosy is also diagnosed with positive skin smears. Sensory loss is a typical feature of leprosy,

Leprosy has afflicted humanity for centuries. It once affected every continent and it has left behind a terrifying image. When M.leprae was discovered by G.A. Hansen in 1873, it was the first bacterium to be identified as causing disease in man. Treatment for leprosy only appeared in the late 1940s with the introduction of dapsone, and its derivatives. Leprosy bacilli resistant to dapsone gradually appeared and became widespread.The drugs used in WHO-MDT are a combination of rifampicin, clofazimine and dapsone for MB leprosy patients and rifampicin and dapsone for PB leprosy patients. Among these rifampicin is the most important antileprosy drug and therefore is included in the treatment of both types of leprosy. Treatment of leprosy with only one antileprosy drug will always result in development of drug resistance to that drug. (Source WHO, 2011)

Our trip to the Kein Khleang Center was extremely profound in understanding the far reaching implications that this disease has on the Cambodians.  The Kien Khleang Centre was opened in January 2000 and operates as a free national referral centre for patients with leprosy complications as well as an outpainet centre providing free consultations for suspected leprosy.  The center offers surgery (debridment of wounds, release of tendons and amputations), physiotherapy, medical management of the disease, food and child care.  We met a family with three small children while we were at the centre who were intrigued by our camera and the instant pictures we were able to produce. 

Mary with Dr. Monica Joyner

Cathy with children who's young mother was afflicted with leprosy

Our tour of the center enabled us to meet many patients.  The loss of sensation in the hands and feet leads to serious injury such as the patient we saw who burned his hand, and did not seek treatment leading to infection and the loss of his fingers.  Many of the patients had plantar ulcers.  This is due to the neuropathy in their feet. 

The Centre provides them with healing sandals but many patients only where them in the home because of the stigma associated with the sandals when they are out in the public.  We couldn' t help but think of the similarities we face a home with our diabetic population and the lack of compliance to wear off loading footwear at all times.  The Centre has a prevention focus providing patients with examples of proper footwear they can purchase at the market and gloves to protect their hands.  Treatment of plantar ulcers includes twice daily soaking of feet in water for 20 minutes and then the application of cooking oil to decrease the dryness and cracking to the feet. In front of the Centre there were rows of wooden benches with bowls of water and several patients soaking their feet.

The Center has iron bed frames with wooden slates.  Woven bed mats are used instead of a mattress and sheet. Clients stay at the centre for 40 days for treatment, education and rehabilitation. We wondered how these patients could tolerated lying on a wooden bed for 40 days, but it was apparent that there is no other options.  This is such an extreme dichotomy to Western health care where there is a strong emphasis on patient comfort. We take for granted the ability to do laundry and disinfect mattresses. There is such a lack of resources here in Cambodia for health care.

We learned that many Cambodians have leprosy and are unaware that they have this chronic disease.  Signs and symptoms present as aching joints or small skin discolorations that are dismissed as the flu or normal skin abnormalities.  The loss of feeling in hands and feet are not understood by these people and injuries are treated at home.  We were told by the Director of the Centre that many Cambodians self amputate fingers and toes at home because they are unable to get transportation for help or do not understand implications of the disease.
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In 2010,  250 leprosy patients received treatment and 114 underwent surgery at the Kien Khleang Rehabilitation Centre.  259 leprosy patients were treated as outpatients.  Because of much needed funding that was received last May the Centre Director was able to do a contact survey to go to homes of suspected families exposed to leprosy.  Due to this survey, 100 people were discovered to have leprosy and  treated successfully.

The deformaties caused by leprosy creates a stigma that erodes the confidence and abilities of patients and their families, thus denying them equal access to education and income-earning opportunities. The Centre helps patients continue to be productive members of society by providing them with loans and education to set up small business or provide skill re-training.

When we left the Centre we asked the Director what he needed to support the sustainability of the program.  He stated he needed people to come for 3 - 4 months to provide treatment such as surgery and wound care.  He needed supplies, such as gauze, self adherent wraps, cling and wound contact layers.

Cathy and Mary with the manager of the clinic

We thought of how a few resources could make a difference in the lives of people with leprosy in this country; a treatable disease that impacts the confidence and income earning potential of so many Cambodians, many who are unaware that they have the disease.

Veterans International Cambodia

Land Mines: The Ongoing Impact on Cambodian People

Land mines were laid in Cambodia from the mid 1980's to mid 1990's by the Vietnamese forces and subsequently the Cambodian Government. Today Cambodia has one of the worlds worst land mine problems and the highest amputees per capita of any country. Over 25,000 Cambodians have lost their limbs due to land mines. (source : Lonely Planet Cambodia, 2010)

We met with Dr Joyner, Plastic Surgeon and headed off with a driver to the Veterans International Cambodia. We went to the rehabilitation department where we were greeted by a physiotherapist and staff. We went into a large room which was filled with parents and children. Many of the children had cerebral palsy and were being given physiotherapy. Some children had limbs missing as a result of coming into contact with a land mine or experiencing a traumatic accident. Several children were born with club feet and were being fitted with special shoes and splints. Many of these children experienced small pressure ulcers and were treated with betadine and gauze mainly because that was all that was available to treat them.

Cathy and Mary with the physiotherapist at Veterans International Cambodia

The physiotherapist took us to see the area where the prosthetic limbs were made. Cambodian people who were skilled in the trade of making the prosthetic limbs worked diligently on forming artificial legs , feet, arms and hands. They crafted rubber into hands and made every effort to make the limb as real looking as as possible. They were focused and hard working. We met with several more patients- one woman who was learning to walk on her artificial leg, and a child that was being fitted for leg splints due to a deformity. Despite their hardships, they all had a big smile for us.

We also saw the area where wheel chairs are made for people in need. While there were many wheelchairs that looked quite decrepid but new wheelchairs  were being newly crafted. There were paintings on the wall that depicted people without limbs walking with a crutch - or wheeling in a wheel chair- but they were depicting getting on with life.  What stuck us is that the Cambodian people were making their own prosthetic limbs and wheelchairs. They were not being imported.

When we walked back to the main entrance we saw posters demonstrating what different kinds of land mines left from the war (Khmer Rouge) looked like. As we left the building we saw a large metal statue of bugs bunny- only there was a twist. Bugs had a prosthetic leg and was holding a land mine. This statue was built by the company who made the machines to detect land mines in a effort to educate children not to touch them if found.

The impact of land mines was very apparent. It was haunting. 

Bugs Bunny with a prosthetic leg and holding a land mine

Wednesday, October 5, 2011

We had a long sleep to catch up and then met with the Plastic Surgeon Dr Monica Joyner for a briefing on the hospitals. We will be meeting Monica tomorrow morning to make the trip to the Leoprosy Hospital and to work with the staff there in the wound care program and meet the patients.We also met a nurse anaesthestist from the United States who is working in the OR at the Hospital of Hope in Phnom Penh as a volunteer for two weeks. They performed a nephrectomy surgery today. We are still very thirsty from the long flight and have been searching for bottled water and drinking as much as we can.