Rajdeep Pooni – Project Angkor

Written by Rajdeep Pooni,MD PGY 2 at Kasier Permanente Oakland Pediatric Residency Program on global health rotation with Project Angkor in Cambodia.

Prior to my trip to Cambodia, I had been asked to list my objectives and expectations for the trip. Given how little I knew about Cambodia (and admittedly this medical mission) I had come up with a pretty typical list: learn about a different culture, understand the medical infrastructure in a third world country, and to leave behind some legacy by passing knowledge onward to native medical students. At the end of the trip, all of these objectives were met. What I didn’t anticipate was how this trip would shape my own view of medicine and the way in which I practice in the future.

On our arrival to Cambodia, there were two days of orientation and travel. Our project site was located approximately two hours outside of Siem Riep (one of the better known tourist destinations) in a city called Sesrei Saosphon. Though this was a cosmopolitan city by Cambodian standards, I was impressed by how rural it was and that it lacked a children’s hospital. Our medical organization, thankfully, was partnered with Angkor Children’s Hospital in Siem Riep. Unfortunately, this hospital was located two hours from where we were working and only the sickest children were sent there. Though this institution serves an important function for children in Cambodia, the hospital cannot treat what are often considered “standard” children’s inpatient ailments such as congenital cardiac issues. Though they have the ability to perform chemotherapy, they are only able to treat the most common forms of childhood leukemias. One of the most interesting aspects of this hospital was that its urgent care/ outpatient clinic where children not sick enough to be admitted to the inpatient ward were kept under “observation” status with their families in what was essentially a camp on the hospital grounds. In addition to being watched and assessed daily, families were taught basic nutrition and hygiene while staying on grounds.

The actual clinic for Project Angkor was located in the heart of Saosophon on the grounds of their one and only hospital. I use the term hospital loosely–patients admitted to this medical complex were unsupervised and supposedly medical staff rounded in the morning to check on their patients. It was pretty disheartening. Regardless, we were fortunate to have this medical complex as our home base, especially given that it was secure and guarded by the governor’s police. Prior to our arrival, there had been recent news about a physician reusing needles and exposing patients to HIV–needless there was much public outrage at the medical community during that week.

The actual clinic days felt so long in the moment, but once finished, seemed to have gone by in a blur. There were many things that seemed so foreign right from the start: no internet/electronic medical devices, no previous medical records, no private spaces or isolation rooms, medical textbooks as a primary source of information, and the general inability to perform routine labs or imaging. One of the scariest parts as a resident was seeing patients completely on your own; though there were two very knowledgeable pediatric attendings with us, there was no way to staff all patients (on average 50/day) with them. These factors alone were enough to make this a foreign experience to a resident in an American training program.

Though there was much medical knowledge to be gleaned from our sickest patients (a boy with a neck mass, a patient with known rhabdomyosarcoma sent home with palliative therapy), the thing I valued most about the treatment and diagnosis of all my patients was that I had to rely on my physical examination skills more than anything else. Even though we were all fortunate enough to have Cambodian medical students as our translators, oftentimes the history obtained was still unreliable or significant pieces of information were unknown. Residents in general are expected to fine tune their physical exam skills, but the unfortunate part about practicing in a developed nation is that we often rely on laboratory tests and medical imaging to tease out a working diagnosis rather than rely on our physical exam skills. Furthermore, we often have previous health records (including previous work ups) that help treat and diagnose patients.

I have no regrets about this experience overall; I would go back in following years without hesitation. The only thing that remains unfulfilled on my end is wanting to see an immediate change in how medicine is practiced in Cambodia. This is indeed a lofty want or expectation. I felt like as a collective unit, our group was able to provide Cambodia’s next generation of doctors with medical information and hands on experience, but the unfortunate thing is that Cambodia at this point and time does not have the funds to allocate to its own medical system. In fact, most upper middle class and residents of higher socioeconomic status travel to Thailand for either emergent or serious medical care. There is no neurosurgeon in the country, and no pediatric cardiothoracic surgeons. It’s tough to imagine, but seeing it firsthand really impressed upon me the importance of patient and healthcare advocacy, not just in resource poor nations but in my own community. The patients that I see in Oakland in some ways are just as poorly off as the many Cambodian families I saw, which is even more shameful given the number of resources available in the States. As a result, I am thoroughly encouraged to participate not only in foreign medical missions but also take more medical ownership within my own community.