Finally, a link to my photos from this great trip!

I can't believe we've been back for almost a month now - and the next team specializing in Cardiothoracic surgery just arrived in Phnom Penh today for their mission. I wish I could join them! Because of the surgery they're doing, they'll be at Calmet Hospital, I believe, which is a little more sophisticated than our Kossamak Hospital. I'm sure they'll do a tremendous amount of good for some very needy patients, and my thoughts are with them..


A few of our Gyn/Onc team members met with the new Neurosurgical team led by Dr. Sean Markey for a 'debriefing' this past Thursday. That team will be heading over to our same Kossamak Hospital in mid-March, so they'll be dealing with pretty much the same O.R. conditions that our group experienced. (And it sounds like they've got some pretty challenging brain tumors lined up already - so another adventure begins!)

We gave them lots of handy pointers (uh, like - be sure to take two Pepto Bismol morning and evening just BECAUSE!!, take the extra-strength DEET, pack lots of hand sanitizer and Power Bars, etc.) - and we may have terrorized them a bit with a few of our stories about the equipment issues over there.  But I've referred them to this blog and the the new link with assorted photos (handily divided into mini albums)- with a few ridiculous mini-video iphone clips at the end. I hope my pictures give them, and anyone else who takes a look, at least an idea of the myriad of feelings we experienced when we were there. What an amazing, great country!

I'm still going to do my two catch-up blogs on Saran's village and The Killing Fields/Toeul Sleng - but in the interim, I've included the photos from those trips in my mobile-me gallery link.

http://gallery.me.com/arnear

Enjoy!!

Jet-Lagged!

Hey all, we got back to DIA around midnight 2/23 (Sat.) - after almost twenty hours of flying/layovers, and security lines.

A few more of us have gotten a little sick either during or since our arrival. We're all jet-lagged to the max, and a bunch of us had to return to work today. I, for one, was certainly functioning on 'auto-pilot' - but everything went smoothly, and it seemed absolutely luxurious compared to Kossamak Hospital. But I admit I missed staring down at my toes in flip-flops during surgery!

I know we're all delighted to be back to our families and American friends - -
Back to beautiful clean hospitals, efficient labs, well-stocked blood banks, proper toilets, safe drinking water and bountiful operating room supplies! ( I am a bit less excited about being back to HIPAA regulations, JCAH rules, Pixus machines, insurance companies, billing codes, malpractice attorneys, 'time-outs', APPLE-PIE mnemonics, and locked anesthesia carts).

No more need for DEET in the Operating Room! - But also no more lovely smiling Cambodian faces, blessedly beautiful children, or grateful patients pressing their palms in front of their hearts, saying "Aw Kun" (thank you) over and over to our team members.







No more balmy breezes, "Dr. Seuss fruit",  Khmer-special $6.00/hour massages, and FOR SURE no motorcycles laden with bananas, multiple rice bags, or live chickens and ducks!!! (yuk..)

 Beautiful Cambodia, poor Cambodia. I believe we all left a little piece of our hearts there. And I, for one, hope to return again someday while I still have the energy and health to help.

Here's the team at baggage claim back at DIA in Denver, bleary-eyed and dazed. But we wanted to say a final thank you to Cambodia and the CMMC/Jeremiah's Hope Clinic and staff for all their incredible efforts and help.  We love you, and miss you already!

For anyone interested (primarily team-members, family, and Cambodian friends, I assume), I'm going to spend the next few days editing and organizing my photos and mini-videos into an online folio that you can access. I need a little more time to let my brain recover and adjust to the ten time zones we crossed in the past couple of days!
I'll divide the folio into albums so you can skip over the more graphic O.R./pathology shots if you're squeamish, and just look at certain subjects, e.g. the "Fabulous Restroom Facilities" sub-album -- LOL :-).
My technical adviser here (aka husband Brian) tells me I can set it up so that you can download any of the photos you like to your own computers - so no need for a flash-drive or disc for my stuff. I'll post the direct link here on the blog, which should make it pretty easy for everyone.

I'll also post a couple of make-up blogs for Angkor-Wat, the Floating Village, and Dr. Saran's village. They were sort of complicated to engineer all the way from Phnom Penh - but too amazing to leave out!

-Thanks for following along!

xoxoxo

Alida

Into high gear in the middle of the night.

We had all gone to bed in anticipation of a big 'tourist' day as our grand finale for this extraordinary trip. Then Gabi began calling Kevin and me - and alerting a few others that we may have a problem with our first patient of the day. Dominique and I began scribbling down supplies we might need while we were still in our hotel rooms since we had dismantled all our equipment.

Gabi and Nancy were worried that the patient may be losing blood into her abdomen, despite the fact that our surgery had been totally uneventful. We wanted to transfuse her, but there was NO O-Positive blood in Cambodia. Yes, none in Cambodia. Though it's easy to get that type in the USA, it's uncommon and hard to find in Asia. We were all asked our blood types, but none of the medical team matched.

Nary called her brother's church members, and incredibly, eight people came all the way to the hospital in the middle of the night to be tested. All our little nursing and medical students did the same, and we found three matches - but those three units would take several hours to process.

Publish Post

At around 1:30am Kevin and I got dressed and called Marilyn to grab her ultrasound machine- and we were swept back to the hospital by Nary, who was in her 'Terminator Nary" mode - totally focused and efficient!. Dr. Sokchan was there to greet us when we arrived. He had sent off a blood count earlier in the evening, and while he was there, the results came back - hematocrit was only 14% (normal is more like 40%). We needed to operate. The operating rooms were locked  with enormous padlocks. We had no blood. Because our mission was over, all our instruments and anesthesia equipment  had been taken back to the clinic, broken down, and distributed all over the place.  Nothing was sterile. I had given away my laryngoscopes, endotracheal tubes and spinal needles and had NO idea where syringes and needles were anymore. Whereas one night before, all our equipment was organized and would have been fairly easy to mobilize, tonight it was a disaster.

But Nary shot me back to the clinic where I threw together the basics as quickly as I could - and returned me to the hospital to set up while the rest of the team worked on throwing together instruments, drapes, etc. etc. etc. The nursing students just appeared out of nowhere, which was extraordinary since without their amazing help we couldn't have pulled this off. Denise and Dominique somehow pulled together the bare minimum number of instruments we'd need for a laparotomy and prepared to crank up their antiquated sterilizer.

Nary and I awakened  "Mr. Ro", who found a way to get the giant padlocks off the operating room doors and helped us find a way to use the sterilizer for the instruments. In the OR itself I had no oxygen, no suction, and no EKG leads!! And I was about to do a major general anesthetic for a significant abdominal procedure. At 2am. In Cambodia. With no blood. YIKES!!!

Kevin and John helped haul in the equipment and the 'critical' bovie electrocautery unit. Kris was there to help soothe the patient just before I put her to sleep, and tuck her under her brightly colored blanket. Mindy and Nancy O were busy preparing the recovery room for what could be our most difficult case yet - and it was now 4am.

And with the help of God and a team that had worked so beautifully together all week, Cambodians and Americans side by side, we faced a really terrifying situation in a strange place, in the middle of the night, and did an AMAZING job!!!.

We had to come up with cash (John and Kevin, thanks!) to buy some albumin to give the patient until the blood arrived (two units at $57 per small 50cc bottle of 20%)- and it was so wonderful to see our little nursing students, all around us in the OR and Recovery Room, with white gauze bandages over the puncture sites used to donate their own blood.

As the sun started peaking through the window, we finished the case. Our beautiful patient was doing very well, and was stable. Dr. Davis and Dr. Sokchan worked together and did an incredible job, staying totally calm throughout.
By now we not only work well together, we trust each other. And the sense of unity and camaraderie in the OR at that moment, in Operating Room A, at Kossamak Hospital - touched me so deeply.

For a while I had thought it was such bad luck that this would all happen in the middle of the night on our last day, with no equipment left. But in many ways I think it gave us an opportunity to show our new friends and colleagues what we could really do as a team, even under the worst of circumstances. The doctors, nurses, and students there were indispensable to us in caring for this woman. I wish we could take them all home with us!

OK, enough drama!!! As we drug our tired bodies out of the recovery room, Nary told us all to go to bed and sleep for a while and forget the touristy stuff, but NOOOOOOO!! We were not, repeat NOT going to miss the Russian Market, Toul Sleng Museum, Killing Fields, OR the big end-of-trip party at the clinic scheduled for that night. So we just kept on goin' - with the help of varying amounts of caffeine! I managed to buy a ridiculous amount of stuff at the Russian Market, even semi-comatose!!

I'm writing this at the LA airport after hours of flying, so I'm going to add the rest of the last-day 'tourist' stuff when I get home. I just wanted to capture the feeling of our last real case there while it was fresh in my mind...

I'll post all my pics and short video clips and give you all the link once I get home and readjust a little!

The Calm before the Storm

We hauled in our equipment for the last time Thursday morning for our final two cases, and they went very well. This whole team is working so well together now, and we're really making a link with some of the local hospital staff and doctors - hoping to teach them and help make some long-term changes for the better in Kossamak Hospital.

I gave a few anesthesia 'goodies' to the Chief of Anesthesia at the hospital and he was very appreciative. I guess he has sort of avoided the team before, but we seemed to have made a positive connection.  He wears STUNNING pink crocs...:-)

Delicious papaya and banana-coconut shakes for lunch!

I noted that I was now used to my Cambodia OR routine:
Upon entering OR, see if there is, in fact, any oxygen available for my machine today. It's all pumped in through the wall, and seems to go out at random - which has not been a huge problem for me since I've been able to do all regional anesthetics, so patients are breathing on their own. Could be a bit of a challenge with a full-blown general anesthetic with the ventilator, etc!
Then I check my machine, kill at least five or six mosquitoes, and spray DEET on my exposed ankles and toes (remember, flip-flops are the official footwear../). Finally I check that I have enough water bottles since the OR is a little hotter than usual and muggy today, and I have to save an empty one for my 'sharps' container.
Pretty funny!

Denise notes that this is "Our last instrument count in Cambodia!!", which makes us all sad in many ways because it's been such an incredible experience. We packed up to make our final exit and distribute instruments, drugs, and all our equipment back at the clinic. We're all feeling nostalgic and sad to be leaving a place where we really feel at home now.

We had a quiet dinner post-massage, of course, and went to bed looking forward to the Russian Market and Killing Fields on Friday - with our final goodbye party at the clinic Friday night.

THEN THE PHONE STARTED RINGING!!!! Our first patient wasn't doing well - blood pressure problems. We all got about an hour's sleep - and it was becoming increasingly clear that we might need to go back in and re-operate. It was midnight.......details  to follow!!

Swiss Fondue, a traditional Cambodian dish...

We had a really good day yestrday. Both cases went very smoothly - after a week and a half here, we're moving like a well-oiled machine!! (OK, maybe not well-oiled, but we're getting SO much better now that we've got a "system"). What's funny is that we just troop into the ORs now as if it's home - so different from the first day when we definitely felt like Strangers in a Strange Land!

We had dinner at, yes folks, a Swiss restaurant - with the amazing Dr. Saran who built the village I discussed a little yesterday. He survived the Khmer Rouge invasion over 30 years ago, and shared with us his incredible and heart-breaking story. I'm going to do a whole seperate blog on him and his village with the clinic and school because I want to do it justice.

But here I want to catch up with a couple of randome thoughts (again!) and funny pics..

Assorted quotes from our trip thus far...

"I am SOOOOOO going to do that  Happy Feet Fish Massage thing!!!!" - Alida N.

"ME TOO!!" - Kris C.


"Give me four advil, a Tiger Beer, and a shower - and I'm good to go!!" - Kevin D.

"Remember, it's CamBOdia..." - said by any of us when we begin to expect things to go at the speed of the US..

"And the ladies will once again be scented with the intoxicating "Eau de DEET", with just a hint of "Eau de Beer" - Marilyn H.

"When you cross da street, be careful... Walk straight, don't look around - just watch for da cars. Motorcycles, bikes and tuk-tuks will swerve around you, but those cars will run you down..." - Van Driver  

"Oh, that's a good shot - you got FIVE of them on one motorbike!!" - John B.
     (That was the first day when we thought five was a lot - we now realize that's pretty conservative)..



Got to go to breakfast... I've got about a million more hilarious quotes from here...Two more cases today, pretty big ones. These will be our last since we got to the Killing Fields, etc. tomorrow before we leave on Saturday...

Spiritually full, but emotionally drained....

Another amazing day....
We traveled 80 km NW of Phnom Penh to Kampong Chhnang province to visit a small rural hospital there with a need for supplies. We traveled in the Magic Bus, again, which, thanks to Nary and Gabi  is always chock-full of cold water, diet pepsi, and local fruit like little bananas, mangostine, and other weird and wonderful stuff!
We got up early to go to the clinic and pack up all the medical items we could spare, since Gabi tells us they have so little, and re-use the same endotracheal tubes and spinal needles over and over, washing them with dish soap in-between. With the HIV infection rate at a whopping 10%, the mind reels at the implications...

.So each of us brought an assortment of goodies. I took  lots of 6.0 and 6.5 Endotracheal tubes which pleased the local anesthesiologist enormously because the larger "normal" size is way too big for these petite people!. I also took a little portable BP cuff (automatic), and a bunch of LMAs which would be SO helpful there (for you medical types).I demonstrated how to use them on a rusty patient cart (open-air, of course) that had empty beer bottles beneath it. I took a big bag of oxytocin ampules since they do about 150 deliveries a month, with a 10% C-section rate. They told me that the American version of the drug is fantastic because "it works!". They usually get the same drug from China which is ten times more dilute and only works on occasion.

There were hilarious signs on the exterior of the buildings. The first small building had a sign saying (subtitled under the Khmer), "Place to Pay Money".  And to the right of it was a "menu" of the surgical procedures available , with the price clearly listed in Khmer. Nari helped translate for Kevin and Nancy C. - noting that a huge major surgery would be about $50 US dollars. A simple wound closure is a bargain at $1.50!! But pay up front or you won't get anything.

The staff was terrific, and very grateful for our visit and supplies..Overall, although they had little, the whole place was very neat and really quite clean - much better-kept than Kossamet hospital where we're working every day.

En route to the hospital, we stopped for a cart pulled by two white bulls, selling pottery. These people spend about two weeks making their wares to sell, then travel in this cart to Phnom Penh, which takes about fifteen days with two-cow-power!. They stay in the city (and sleep in a little area in the middle of the cart) for as long as it takes to sell everything, then had back home and repeat the process.




  For those of you reading this that are horse people, they have the cows wear these cool little flip-flop things to protect their feet - a neat variant on our E-Z boots for horses !! Hilarious, and even color-coordinated with the same colors on the front, and different ones on the back. The cattle here are respected and loved because the people are utterly dependent on them to pull their carts and plow. If not working, they're turned loose to roam the countryside and drift across the road (there are no fences) - then at night they all just migrate back to their proper homes for dinner. Really cool.





From here we went further into the countryside where we had the privilege of visiting Saran's (sp?)clinic and school for local children. He bought land and built this lovely haven in an attempt to educate the children in French and English as a way of keeping them away from begging or falling into the child prostitution that is so prevalent here. Many of the children are victims of child abuse by family members and others. Horrifying. But their smiles are so gorgeous and hopeful.

This is where I walked around with tears in my eyes at the beauty of the children, and the oasis of safety and learning that this man has created in the midst of such poverty. I'll post pictures and more tomorrow.

So many of these days I go to bed and just cry for a while - not because I'm sad, but because what I see here fills me to the brim with genuine hope for humanity, despite the desperation and poverty.
The inherent innocence, honesty and goodness of these people, children and adults alike, really helps bring  me back into touch with the same qualities in myself. This place and these people have sort of forced us all to peel away those protective layers that build up so easily against the craziness of life back home. It's been therapeutic, inspirational, and transforming..

Just look at those faces!!! :-)

Mexican for dinner????

Ok, on our list of must-do activities was riding in Tuk-Tuks... so we can check that one off after tonight! Kevin  did the all-important negotiation for the group, and got our price from a whopping $5 to $3 for the group. And what a cool way to travel   -  but it's WAY better to ride in the front seats so you face backwards and can't see the five million cars, motorcycles, amd bikes that are careening around in front of your vehicle. It's like being in the middle of  a video game except YOU are one of the little objects about to get zapped!

We also felt it was critical that we eat dinner at the only MEXICAN restaurant in Phnom Penh which, Gabi assured us, would be delicious. Needless to say we're all getting a little burnt out on RICE, and were ready for a taste from home. SO, we tuk-tukd (hmm, is that a verb??) to The Cantina. Kris (one of  the Massage Regulars), Nary and Gabi in pic above. It was great, and wonderful to see the Mekong riverfront area at night. (though there were a few hefty-looking rats skittering along the banks)..

We're headed to Kampon Chhnang province tomorrow to take donated supplies to a small regional hospital there. Heading to bed now!

Oh, so far everyone has had some variation of the Tourista except Nancy C. and me....I'm sucking down prophylactic Pepto and eating vegetarian.. Keeping fingers crossed!

Monday, Monday...

Our first patient today was the toughest yet.. She is HIV positive, widowed, extremely poor - with cervical cancer. She was quiet,  sweet and so clearly grateful for our care. These patients walk into the OR, amidst a mass of foreigners in strange blue outfits and masks, and are so absolutely trusting. Even while she was sitting on the table, bent over to get her spinal block, this lady held her hands in 'prayer' position repeating "Aw Kun" (Thank You) to all of us. With each case I love these people more and more.



Kevin and John (aka Dr. Davis and Dr. Bell), our amazing surgeons,  did a phenomenal job under very difficult circumstances. They are operating with only a fraction of their normal equipment, but managed to make-do with what was around, even when the going got pretty rough. I also have to modify my anesthetic options to maximize safety since every aspect of care here is significantly different from home (e.g. the OXYGEN cut off for over twenty minutes today, and there are no back up tanks or supplies of any kind - a llittle nerve-wracking to have all the dials go dead and see that red "No O2 Pressure" sign... :-0).

We needed to unexpectedly transfuse this patient - which means the family members had to line up and donate blood to the blood bank BEFORE the hospital would realease a matched unit to us.

Tonight she's doing great and is very stable.  We're exhausted, and heading for our first Tuk-Tuk ride to a restaurant!