Cambodia 2013

Situated at the confluence of three great rivers, the Mekong, Tonle Sap and Bassac , Phnom Penh is the heart of a country steeped in tradition, overflowing with paddy fields, jungles and untouched rural communities. Once a sleepy backwater, Phnom Penh is changing, but the old french colonial mansions which are now overseeing the capital's development also witnessed more difficult times from which recovery is incomplete.

Setting off from autumnal London , the heat and humidity of Phnom Penh seem a world away. On Thursday, I fly to Cambodia's capital, to its Children's Surgical Centre to offer whatever help is required over the course of a week. It's a great privilege to have the chance to be able to make this visit and I feel very fortunate to have the opportunity.

The trip is being supported by BFIRST. This charity supports plastic and reconstructive surgeons to travel to under-privileged communities, to teach local surgeons and to treat impoverished patients without charge.

What stories will unfold over the course of next week is uncertain, but what is clear is that the work will be very different from that which I am used to in leafy Hampstead.

The frenetic streets of Phnom Penh revive the senses after a long flight across two continents. The smells of the street food and the sights and sounds of this city are unmistakably those of South East Asia; while not as westernised perhaps as Bangkok and not quite as chaotic as Ho Chi Min City, with Cambodia’s capital located between the two, the culture and gastronomy are nevertheless instantly recognisable.

Strolling around, it’s hard to believe that on April 17th 1975 when the Khmer Rouge swept into town, this bustling metropolis was all but deserted by its inhabitants, as schools were banned and the townsfolk sent to the countryside to work the land.  Visiting Toul Sleng Prison Museum and the Killing Fields of Choeung Ek in the outskirts of town, brings the horrors of the following four years into sharp focus.

The cruel and inhuman Pol Pot regime left millions of land mines buried in the Cambodian countryside, unexploded and lying in wait. Added to these are the millions more left by the invading US forces when the Vietnamese conflict spilled over its border some years earlier. The vast numbers of amputees in rickety wheelchairs on the streets of Phnom Penh today, serve as a reminder of the futility of war and give a disturbing perspective to these essentially political conflicts. Many victims of the land mines were born years after the events which sought to justify their use and the hospitals of Cambodia are witness to the suffering for which these terrible weapons are still responsible today. Of course the patients attending the Children’s Surgical Centre will present with many and differing needs, not only the result of war. Tomorrow, I’ll be meeting my colleagues there for the first time, as the working week begins.

The waiting area was filled with patients and relatives long before the clinic opened on Monday morning. Some had been brought from remote rural communities by charities, others had travelled long and arduous journeys with family members, but all would be seen and a treatment plan determined.

Jim Gollogly, a Middlesbrough native and founder of the CSC welcomed the staff and led discussions of the surgical procedures planned for the week. One by one the patients were presented to the assembled doctors.

There were some for whom treatment could not be offered: A young brother and sister, not yet 7 years of age, weakened by terminal muscular dystrophy and barely able to stand; a 20 year old with a large vascular malformation of the lower back, ulcerating and likely soon to bleed heavily; an 18 year old brought to the clinic by a Belgian charity, with an inoperable cancer of the bowel.

But for every story of incurable disease, there were others of patients with life threatening conditions that could be treated. The operating room, where four procedures are performed side by side, was busy by 9am sharp and there the local surgeons and volunteers from abroad would remain until dusk.

The enormity of the workload before us allowed little opportunity to reflect on things and I was pleased to be able to start helping in some small way. First for a lady who had suffered severe hand trauma and lost her thumb, then for an old man who had presented with a cancer invading into the sternum. The third case was of a young man who had sustained a severe burn to both arms as a result of a huge electric shock. Sadly all of the nerves and tendons of the wrist had been destroyed by the burn and were by now dead and infected.

Excising this tissue would save his life, and his paralysed hands could be treated later.

Our young man with life threatening sepsis following electrical burns was diagnosed with tetanus infection overnight. Severe and painful muscle spasms arched his back and caused him to clench his jaw tightly shut and as septicaemia worsened his condition seemed hopeless.  

Meanwhile, in clinic, patient after patient presented with injury to the brachial plexus – the spaghetti junction of nerves in the neck that supply the arm and hand. These injuries are often the result of a moped accident on Cambodia’s treacherous roads, as the rider lands awkwardly and stretches the nerves beyond breaking point. Today’s operations at the hospital included using nerve grafts and tendon transfer procedures for these patients after which some recovery can be expected.  

We also saw several children with severe burns. Much of Cambodian life in rural communities has not changed in a thousand years, with reliance on fire for food and for warmth at night. Toddlers, free to enjoy their new found independence are drawn to the flames with inevitable consequences. Their hands grasp red hot embers which melt fingers thumb and palm together and all are then lost in a ball of scar.  

Today I will operate on two such children and several others undergo procedures by my Khmer colleagues, to unpick the fingers and thumbs, to re-open palms, using skin grafts and more complex “skin flaps” to fill in the gaps.  

To be prehensile again gives these vulnerable children the chance to return to their lives and their schools and one day to plough the fields, harvest the rice and support families of their own. 

95% of Cambodia’s doctors were murdered by Pol Pot in the late 1970s. And yet today’s Cambodian surgeons, without the teaching of the generation before them and without the infra-structure of the west, are highly capable, operating in challenging circumstances and with very impressive results. The same can be said for the physicians and the nursing staff.  

Our patient with tetanus and a grave prognosis, was treated with professionalism and expertise by the Khmer staff today and by evening, they had saved his life. 

 
Before coming to Cambodia, I had offered to see children with congenital ear deformity (microtia) at the hospital, as auricular reconstruction is one of my specialist interests. The expertise for microtia surgery is unavailable in Phnom Penh and so, aside from treating patients, my visit was a good opportunity to teach the principles of the techniques involved to local surgeons. With the combination of regular visits by recognised (ISAR*) ear reconstruction surgeons along with the training of Cambodian doctors, together with the support of charities such as BFIRST, the long-term provision of a microtia service for Cambodia can be envisaged.
*ISAR – International Society of Auricular Reconstruction

In total six patients were brought to a specially convened clinic. The first patient was little boy, 7 years of age, who had a fairly typical right sided microtia. He can expect a very good result from surgery on a future visit, but he was a too small to undergo reconstruction on this occasion. 

I then saw a six year old girl whose parents were also offered the option of returning two or three years hence. The next patient, a 9 year old girl, was offered an operation but she preferred not to go ahead following a long discussion about what the surgery entailed.  She may change her mind in a year or two and if and when she feels ready I would be happy to offer surgery again. 

The gold standard operation in microtia reconstruction involves sculpting rib cartilage into an ear-shaped framework which is then placed into a skin pocket at the site of the microtic ear. This gives a durable and very realistic ear reconstruction which lasts a lifetime. The next two patients, both with microtia, one an adolescent and the other a twelve year old girl, agreed to the surgery.

Microtia surgery is highly specialised but with an enthusiastic nursing team and Dr Davy, a local ENT surgeon as my assistant, both of the operations went well. The surgical instruments are not quite as refined perhaps as those I am used to in the west and this adds to the challenge of the surgery, but with the help of my Cambodian colleagues the result of both reconstructions was good.

The final patient who attended the ear reconstruction clinic was a young lady who had suffered severe facial burns some weeks before and had lost a significant portion of her ear as a result. She was desperately upset about her injury and very keen to undergo a reconstruction on this visit, but with the wounds still being raw, it would not have been correct to attempt surgery just yet. Along with the other patients with microtia for whom surgery had been deferred, I hope to be able to offer an operation the next time I am in Phnom Penh.

On my final day at the clinic I met Mohapanha. He was a normal, active 18 year old student until he was injured in a moped accident some months previously. He sustained facial injuries, with severe trauma to his right eye rendering him permanently blind on the one side. This was complicated by wounds to his eyelids which had then healed to the conjunctiva, tethering the right eye in place and restricting its movement. Because the right and left eyes move together, the uninjured left eye’s movement was also affected.

The operation to release the scarring of the lids to the conjunctiva was simple enough and allowed both eyes to move freely. The upper and lower eyelids were then released from one another and the eye’s dimensions were returned to normal. These aesthetic and functional changes were easy enough to achieve, but will give a little hope back to Mohapanha after such an awful injury.

Back in the clinic, patients were being reviewed following surgery by a group of craniofacial surgeons from France, the week prior to my visit. Many patients with skull defects (meningo-encaphaloceles) and severe deformity (neurofibromatosis) had undergone successful surgery and returned for their follow-up appointments happy to have undergone treatment at the Children’s Surgical Centre.

 It's six months since I was last in Phnom Penh and the chance to go back to the Children's Surgical Centre has fortuitously come around again, thanks to BFIRST, the charity which sponsors my visits. On this occasion, I will be joining colleagues from Scotland and Singapore to teach reconstructive surgery techniques to the local Khmer surgeons. I'm very humbled to have the chance to return to this beautiful part of the world and to catch up with the colleagues and friends I made six months ago, not forgetting one very important patient.
 

 Phnom Penh wakes well before the dawn, before the sweltering sun punctures the cool air of early morning, before the heavy humidity of late May traps the city under its sultry weight. The metropolitan Cambodian makes the most of this time of half-light as Tuk-Tuks vie for space with scooters and pedestrians on the city's hazardous streets.

By the time I cross the Japanese Bridge over the Tonle Sap river, the heat is almost unbearable. Arriving at the Children's Surgical Centre once again, it's as if no time has past since the last visit. As if, after a weekend away, Monday had come around, and we were to pick up again from where we had left things the Friday before.

There to greet me was Dr Davy, the local ENT surgeon, who had helped me reconstruct a little girl's ear six months previously. She had arranged for the patient, Chuon, to return to see me for the second stage operation.  

 It was a real delight to see Chuon again. She had been born with a condition called microtia in which the ear doesn't form properly. The reconstruction had involved removing cartilage from her ribs and sculpting an ear shaped framework to place under the skin on the left side of her head. Her bravery, and her acceptance of the procedure at such a tender age had made a real impression on me. Fortunately today's operation to release the ear from the side of her head and to give it prominence, would be much easier for her.

Once again, the staff at the Children's Surgical Centre were very welcoming, highly skilled and enthusiastic and the operation was a great success. In the photo, Chuon and I had tried to talk to one another, but with my Khmer not being as good as it could be and without an interpreter it wasn't easy! But she was smiling and happy, and for my part, Choun's reaction alone had made the whole trip worthwhile.  

R

 After a long, tiring but thoroughly rewarding week working in Phnom Penh, I wanted to make a trip to Siem Reep before the long journey home. Over hundreds of square kilometres around this north western corner of the country, close to the border with Thailand where so many suffered during the time of the Khmer Rouge, are found hundreds of temples dating back well over a thousand years.  I visited many of them, over two days but I could have spent two months and not seen them all. Of course, I visited the most famous of all, which is of course Angkor Wat (above), an immense structure of breathtaking beauty. I was there in the heat of the afternoon, when temperatures reached well above 40 celsius and the humidity was palpable. As the sun set, and the old stones exuded ever changing colours, I reflected on Cambodia, and the stark contrast of its beauty and its tragedy.
 

 Cambodia is a majestic place, and the Khmer are a gracious, happy and welcoming people. It is a country blessed by an abundance of natural resources and a rich culture. Yet as fish spill over the shores of Lake Tonle Sap in the wet season, and great forests grow through its ancient temples, most Cambodians are poor, terribly poor, and with no access to the healthcare much of the world takes for granted. To those with healthcare skills who wonder how they can help the impoverished and the destitute of this wonderful land, if you visit the answer will be clear. Time. Give them your time.