The Kingdom of Cambodia is getting back on its feet after years of revolution and government turmoil. So too is the Cambodian medical system. It still suffers from enormous under-funding and corruption, but the orthopedic care is slowly developing. SIGN is now a highly sought after system and used in 3 provinces. I went to Cambodia for the month of December as a third year orthopedic resident from the University of British Columbia. I was hoping to learn about the SIGN nail, about acute trauma and about how orthopedics is practiced in the developing world. I did all of this and much more.

My base was Phnom Penh, a wonderful city, full of reminders that this was once a French colony. I divided my time between Sihanouk Centre of HOPE Hospital, run by an American NGO and Kossamak Hospital, run by the Cambodian government. Dr Tim Keenan, a retired Australian orthopedic surgeon was there to greet me and show me how things work in Phnom Penh. He was overseeing the English orthopedic training program at HOPE and Dr Duong Bunn was in charge of the Kossamak French program.

The surgeons in Cambodia are all general surgeons but some have more interest in orthopedics than others. A few, like Dr Bunn, have been sponsored by the French government to do fellowships overseas and are now teaching back at home. The vast majority are trained by experience. Years of war and residual landmines have produced thousands of orthopedic patients. With few resources they do the best they can. There is no orthopedic residency program as we know it.

This put me in a great position. I was already somewhat of a specialist so I was able to share what I knew, however, I was also a student and they were happy to teach and show me their way of doing things. As a fully trained surgeon I may have missed out on that opportunity to learn. I had also just spent three weeks in the Philippines, observing how they use the SIGN nail and it was exciting to share some of the techniques I learned there with the surgeons in Phnom Penh.

I participated in surgical rounds each morning (and learned more about goiters than I ever needed to know), then headed to the OR for the day’s cases. There were usually two or three on the slate. At the government hospital, equipment was hard to come by and an active imagination was required to make what you needed out of the available supplies. All activity except emergency care stopped at noon at Kossamak as the doctors went to their private clinics in the afternoon and the nurses rested.

I also had the opportunity to visit two other hospitals in Cambodia during my stay; Kampong Cham and Siem Reap Provincial Hospitals. In Kampong Cham the orthopedic surgeon was away in France getting further training. In Siem Reap, they are anxious to learn the SIGN technique. Currently, they plate all fractures requiring surgery using donated bits and pieces. The surgeons there are furthering their training by planning trips to Phnom Penh.

It wasn’t all work though. The junior surgeon in Siem Reap, Dr Samon took me for a ride on his moto to see the countryside one afternoon. We stopped at an ancient temple of the era of Angkor Wat and had the place to ourselves. After exploring the temple, he took me to be blessed by the head monk. We were seen in his home, a bamboo and woven palm leaf hut with a mat on the floor. After doing several calculations with Dr Samon’s birth date and other personal information, the monk told him that his dream of studying orthopedics in France would come true. I am not exactly sure how he determined this, however he was thrilled and I felt honoured to be a witness to the exchange.

Tim Keenan and others have been facilitators in the organization of a Cambodian Orthopedic Association. This group gathers annually at a scientific meeting. They also host bi-monthly orthopedic rounds at different hospitals in Phnom Penh where surgeons are welcome to present difficult cases to the group. An interactive discussion then follows. At these meetings, I was amazed to see how much of a problem tuberculosis is in Cambodia, manifesting itself in many ways. This is something we rarely see in Canada. Mal-unions were also incredibly common with patients sometimes seeking treatment ten to twenty years after the fracture.

Traditional healers and bone setters are an integral part of Cambodian culture. Each town or village has at least one. They are less expensive than seeing a doctor and often more accessible. Bamboo splints, balm, wraps and herbal medicines are their tools. Unfortunately infections and mal reductions sometimes prevail and eventually come to medical attention.

I learned a lot in Cambodia, both from a social and a medical perspective through SIGN. It was a priceless experience for me. It is a country that’s slowly recovering from atrocities that happened within my lifetime. The orthopedic care along with everything else in the country is improving with the help of NGO’s and dedicated Cambodians. They have been through so much. I am fortunate to live in Canada and after meeting my friends in Cambodia, I know that I know I’ll never complain about another “rough” night on-call again.