Cambodia - March 2008

Gardens are an integral part of the ambiance of Emergency's hospitals, clinics, and first aid posts. Even in the dry season, the small garden at the Surgical Centre in Battambang welcomes a visitor with manicured soft green grass, a profusion of brightly colored flowering creepers covering the freshly painted white walls of its buildings, and an immediate sense that a patient will be well cared for here.

The hospital was built in Battambang because the provincial capital offered some amenities, and because it is close to the mine fields that were planted along the nearby Khmer-Thai border during the civil war. This part of the country, far more than Phnom Penh, has a history more deeply tied to that of Thailand than Vietnam. Land mine victims are still a component of the hospital's census. Large scale de-mining operations will be working in the country for years to come, while the threat of injury caused by the natural movements of soil, due primarily to rains, will always be unearthing mines, making rural life doubly difficult. Not all the de-mining operations are thorough. One day patients from two accidents from land mines arrived at the hospital--both occurring in fields that had been planted in previous years and presumed to be de-mined.

Up until early 2007, besides war related injuries and acute surgical abdomens, the hospital didn't treat a lot of trauma, concentrating on huge goiters due to IDD, hernias (the bane of malnutrition), and uncorrected congenital deformities, primarily TEV. (Also noted: a surprising number of TEV associated with Amniotic band syndrome. I'd only seen 2-3 such cases in the past and all in Africa, but in 2 months came across 4.) Another reason trauma wasn't high on the organization's priority is that the international staff was generally limited and primarily focused on general surgeons.

In Feb 2007, Emergency signed a memorandum of understanding with the Battambang provincial health authorities that it would continue to take care of war related injuries, all trauma, all acute surgical cases and cases of orthopaedic deformities. The main thing Emergency was giving up were infections, though those due to open fractures and war injuries are still accepted. In mid 2007 to accommodate the ortho trauma, it changed its ward distribution, sequestering one ward for closed treatment of fractures and for infections. This left 2 wards--a 46 bed male ward and a 26 bed female/children ward for pre and post "clean" surgical patients. This basic change has significantly helped keep the infection rate low. Also Emergency asked Milan for sets to do internal fixation because it didn't have any--large and small fragment sets came in April, SIGN nails in May-June, and a set of large cannulated screws. The hospital has an old C-arm which is on the brink of falling apart, though is satisfactory for doing closed pinning of pediatric supracondylar fxs, and a very old fracture table that is basically unusable. No implants to treat inter trochs are available. In many ways fixing these would be a hindrance since there is neither the time nor personnel to adequately treat them. There are too many other fractures in a more productive population that will benefit from relatively simple treatment. Many surgeons do not like being faced with making such choices, but it is the only way to preserve sanity while taking care of 80 ortho patients, making productive daily rounds, sorting out 6-10 new admissions/day, and keeping track of an OPD that sees between 30-40 cases/day.

There is one interesting ward, F ward, separate from the other wards, where patients can be admitted before surgery. For example, a patient is seen in OPD who needs surgery, but he has had a POP and the skin is not in condition for surgery. So rather than use a "good" bed, the patient is sent to F ward where about 30 patients sleep on the floor on mats. After BID showers and a bit of Vaseline, the patient is seen back in OPD in a few days to see if the skin is ready for surgery. All the SIGN nail patients went to F ward once mobile on crutches, to wait out their time until suture removal, since many of the home environments are filthy. It was a very useful set up and allowed beds on the regular wards to be more efficiently utilized and allowed patients intense physio, that they wouldn't have not received had they been discharged. It was also a friendly gathering place for the patients. In the early mornings they'd sit outside digesting their breakfasts and greet me with deeply bowed sompiahs.

Physio is an integral part of the hospital and the physios prefer SIGN as opposed to Perkins traction. Genetics, I suppose, plays a big part in bone strength, along with no ready source of calcium in the diet. Having a couple of fractures in polio-porotic bones was also a challenge. This severe osteopenia seemed to change the configuration of common fractures.

The nurses in the OR are singularly pumped-up, ready to work, always eager to learn something new. They were my biggest help and very accommodating to get the drills and sets sterilized so we could do another case. If I said I'd be back from OPD in 40 minutes, they knew I'd be there, on time, and would have the patient ready, just waiting to inject the anesthetic, tourniquet on, antibiotics given, etc. The decent work of the nurses in the wards, opd and OR, along with the physios helped get the work done.

SIGN has made a huge impact on the hospital. The patients even know this one English word and are proud that they have a SIGN nail inside their bone. Merja commented that it was the best thing that ever came to the hospital, though not everyone at Emergency feels this way. The ICRC no metal rules remain a major part of Emergency's internal creed.

I can say the Emergency hospital in Battambang is presently set up as place where good work can be done--a similar feeling that I have about Kabul. Much of this has to do with the strong humanitarian culture of Emergency that transcends any local deficiencies, working to achieve basic, but high standards of patient care. BunLee will do very well with the database. He was a monk for 10 years where he learned his English. Like everyone else at the hospital he understands the value of SIGN in a way that I would not expect from someone who is not intimately involved in a surgical way.

Michelle Foltz, MD