Further to a Humanitarian News article published in the November/December 2014 issue of ENT and Audiology News (see article here), this is a report of Charlie Huins’ six-month experience as the first ENT Fellow at the Children’s Surgical Centre (CSC), Phnom Penh, Cambodia.
Arrival
Arriving into such a new environment was an exciting yet daunting prospect. It would prove to be both a refreshing change and a real reminder of why we all went into this game in the first place – to treat those with barely a penny to rub together who, with advanced disease that the local healer cannot cure, present to the doctor as a last resort.
Dr Davy presenting a potential surgical patient’s case in the morning meeting.
CSC’s director, Jim Gollogly, welcomed me to Phnom Penh and provided invaluable support both clinically and socially. Since our preliminary visit in 2014, Jim had sourced two operating microscopes with a linked flat screen for teaching. Micro-instrument sets were created from donated used equipment; head rings and two Visao drills were kindly donated by AneticAid and Medtronic respectively.
Cambodia is still recovering from the genocide of the 1970s and surgical ENT services remain scant; indeed, I was to be the only mastoid surgeon in a country of 15 million people.
The service
Our team comprised three junior doctors and two nurses. I quickly recognised the need for writing policies, protocols and introducing the WHO checklist; preparing timetables, tutorials; ordering and organising equipment and supplies. The team had no prior experience of otologic surgery and so this was to be a lesson in not just teaching the technicalities of the procedures, but also educating them in how to choose which operations to do in the first place.
Wearing shoes indoors is culturally unacceptable, adhered to by the patients.
Teaching Kosal, one of the trainees.
Saying goodbye to the lovely ENT department.
Receiving my certificate from CSC’s director, Jim Gollogly at the end of my fellowship.
Chronic active mucosal otitis media presented more commonly than cholesteatoma, so I concentrated on teaching tympanoplasty techniques. We achieved our aim of the local doctors being able to operate solo by the end of my fellowship, as we performed 96 tympanoplasties together. I also performed 34 mastoidectomies for cholesteatoma, largely front-to-back following the disease, since preoperative CT was rarely available and cost prohibitive, and the concept of second-stage procedures unrealistic as our patients would return to their remote villages, rarely to be seen by us again.
Our main referral pathway came through All Ears Cambodia (www.allearscambodia.org), an NGO established by Glyn Vaughan, an audiologist from Charing Cross Hospital, London, UK. It proved a mutually beneficial arrangement. They provided the pre- and postoperative audiology, plus postoperative mastoid cavity care through four centres around the country. In return, they now had a point of referral for their chronic ear patients and I contributed to a teaching programme for their audiology students.
For the Fellow
In such a brief report it is difficult to emphasise quite how much I learned and benefitted from this experience, raising my competence and confidence, both surgical and managerial, to a whole new level. I regularly dealt with much more extensive disease than I’d been exposed to in the UK due to its late presentation, without the back-up of preoperative CT scans or intraoperative facial nerve monitoring. I was continually grateful for regular remote support and advice from my colleague, Matt Clark, to discuss approaches to difficult cases. Learning how to manage a team and getting them to work to the best of their ability was challenging, especially in a different culture. It was a fantastic exercise in self-restraint, service organisation and workforce planning.
The practicalities
Phnom Penh is a rapidly developing metropolis: the large tourist and ex-pat communities are served by a range of bars and restaurants, plus a number of gyms. For those with families, child-care is readily available. I rented a nice apartment, a 10-minute commute to work on my second-hand scooter. Cambodians are a warm, smiling and friendly people and I never felt uneasy or threatened. The post funded my return flights and a wage that more than covered living expenses. Taking leave was straightforward, allowing me to travel further afield to sites such as Angkor Wat.
Summary
This is a unique fellowship for post-CCT otologists with an adventurous spirit. The transition from trainee to independent practitioner is a big step and I found this experience to be that perfect bridge between the two.
For further information and to apply for the post, please email either Mr Matthew Clark or myself.
Declaration of Competing Interests: None declared.
