• Cambodia

The Paediatric Surgery in Cambodia Project was initiated by the Kind Cuts for Kids Foundation chair, through the International Federation of Surgical Colleges (IFSC) and was assisted by CARE International. The work commenced with a feasibility study in January 1995 and was carried out with the financial support of the IFSC and CARE Australia. Four visits took place, including one each by Paddy Dewan, Tat Hin Ong, Lawrence Smith and Martin Glasson who have worked in Cambodia for a month each, between November 1995 and October 1996. The project has been frustrated by a lack of infrastructure for the surgical treatment of children, the inability of a Cambodian medical staff member to become involved in patient recruitment, the presence of a Paediatric facility which runs counter to World Health Organisation principles and the need for the project to be largely a diplomatic development exercise in its early stages. However, many children have been treated and a large number of medical students, doctors and nurses have received some education in Paediatric Surgery. The International Federation of Surgical Colleges, CARE Australia and CARE Cambodia assisted greatly with the project and Tat Hin Ong, Laurence Smith and Martin Glasson gave their time generously.

The following is a summary of the work performed during the four months in 1995/6.

Patient Care

A total of 265 patients were seen during the four months and 62 operations performed, the majority during the first visit.

Clinics

Clinics were conducted in the squatter settlement in which CARE assists in other ways and in the Kein Kleang Orphanage run by Friends for all Children and children were seen at the National Pediatric Hospital and on the wards of the Preah Kossamak Hospital.

Operations

Genito-urinary Surgery 17
General Surgery 38
Orthopaedic 7

While a number of the patients operated on were adults, most were children and the principles of management in the theatre and the ward were focused on the care of children. The target for children will easily be reached.

Teaching

Teaching was conducted during 7 clinics, 43 ward rounds, 50 lectures and 36 operating theatre sessions at the National Children's Hospital, the Preah Kossamak Hospital, King Norodom Sihanouk Hospital and the squatter settlement.

Final year medical students, medical assistants, residents, trainee surgeons and consultant surgeons participated in the training sessions. The lectures during the first visit were attended by an audience of 10-20 people, but up to 40-60 during the second visit and the ward rounds were often joined by 2-3 doctors and 4-6 medical students.

Lectures

The following formal lectures given were at the Preah Kossamak Hospital and the National Pediatric Hospital:

1. Hirschsprung's disease, including diagnosis, surgery and colostomy formation.
2. Neonatal vomiting, including malrotation, pyloric stenosis and gut atresias.
3. Inguinal scrotal pathology, including hernia, varicoceles, embryology, anatomy, surgery.
4. Hypospadias and intersex, including diagnosis, embryology and details of surgical management.
5. Acute scrotum, including testicular torsion, torted appendage, urinary infection, medical and other surgical differential diagnoses.
6. Vesicoureteric reflux, including surgical treatment and urinary tract infections management.
7. Renal tract obstruction, including pathology, diagnosis and surgical management.
8. Resuscitation of children, including maintenance, replacement and dehydration assessment.
9. Introduction to Paediatric Surgery.
10. The equipment for surgery.
11. Surgical conditions of the head and neck in infancy.
12. Paediatric surgical emergencies.
13. Common conditions on paediatric surgery.
14. Abdominal Pain in children.
15. Management of severe multiple trauma.
16. The child with bleeding from the stomach or rectum.
17. The neonate or child with vomiting.
18. Congenital anorectal and cloacal malformations.
19. The child with wetting.
20. Respiratory distress in neonates and children.
21. Swellings about the head and neck.
22. The constipated child.

Ward Round Tutorials

The following topics were part of the ward round/tutorial teaching:

Genito-urinary

Urinary obstruction, ovarian pathology, hypospadias, hypospadias post-operative care, bladder cancer, vaginal injury, haematuria, renal calculus disease, urethral rupture, urinary catheter obstruction, intravenous pyelogram assessment.

Trauma

General examination, hypoproteinaemia, intravenous access, burn management, splenectomy management, amputation planning, sciatica, nerve root distribution, central nervous system examination, back injury, head injury, fluid resuscitation, chest trauma, bullet injuries, radiological screening, radial dislocation, compound fractures, multiple injuries, limb trauma.

Other

Abdominal pain, masses - surgical sieve, anorectal anomalies, breast cancer, abdominal masses, clinical examination and management, spina bifida occulta, heart disease, herniae, malignancy, blood use, death and the family, pelvic infection, first aid treatment of wound infection, femoral osteomyelitis, intussusception, post operative care, caecal carcinoma, differential diagnosis of abdominal mass, acute abdomen examination, assessment of elderly patients pre-operatively, naevi, Hirschsprung's disease, wound infection prophylaxis, wound cleaning, infection, polyps.

Teaching in Theatre

The staff involved in theatre education included more than 11 surgeons who received training while assisting with operations.

It is hoped that the project will continue when World Vision completes a surgical building in the National Pediatric Hospital and the political climate becomes more conducive to real progress. The next phase will hopefully consist of four teams of three people (surgeon, anaesthetist and nurse), working for a month each, to teach, operate and contribute to strategic planning.

As a result of contact through the project, Dr Chi Mean Hea is currently in New Zealand for further training. After his subsequent return to Cambodia it is hoped that he will help further develop Paediatric Surgery in his home-land. Dr Hea is now a significant member of the Department of Health in Cambodia.