Participants

Rune Nilsen, Sophies Minde
Thomas Glott, Sunnaas Rehabilitation Hospital
Sathia Kim, Cambodian Trust

Programme

Wednesday June 3rd
14.00-15.30 Welcome and planning program for visit

Thursday June 7th
8.00 – 10.00 Ward round. Demonstration and discussion of patients
10.00-12.00  Meeting with Battambang provincial department of Social affairs, veteran and youth rehabilitation with Mr Kong Vutha, Deputy Director

14.00 -15.00 Meeting with Deborah Rutherford at the Emergency hospital
15.00 -16.00 Meeting with vice director in Battambang provincial hospital Dr. Bun Hieng. Visit to the acute ward and a recently injured incomplete tetraplegic (fall accident) with Dr. Pin Sovann.

Friday June 8th
8.00 -9.00 Training and physiotherapy. Demonstration and discussion of patients (complete tetraplegic car accident, medullary tumor L3 incomplete paraplegia, complete paraplegic hit by falling tree).

9.00 -10.00 Visit with the staff at spinal center. Information about Sunnaas rehabilitation hospital and discussion about future plans for projects and cooperation.

10.00 -11.30 Visit to paraplegic woman in Battambang. Ms. Horn Saly  Aged 45 year injured in fall from tree in 1988. Admitted to the spinal center i 1994 and three times later because of pressure sores, pregnancy and post-delivery. Husband works at the center as a guard.

14.00 -15.00 Summary and discussion of plans for further cooperation

Monday 8th  June
17.00-17.30  Meeting with secretary of state in the Ministry of Social affairs, veteran and youth rehabilitation Phnom Penh his Excellence Sem Sokha.

Background

The center was built an supported by Handicap International France from 1993. Handover to local authorities was planned for the 3 last years. Handicap International France stopped funding the center from January 2009. There was a gradual decrease in funding over the last year but significantly from 2008. The center has closed beds and reduced staff significantly. The intention of the visit was to establish coorperation between Sunnaas Rehabilitation Hospital and Battambang spinal cord rehabilitation center.

Financial situation

During support by Handicap International France

Annual budget in 2007:  USD 175 436.
Expenses in 2006: USD 145 601.
Situation in 2009 is about USD 4500 pr month. Estimated annual budget in 2009: USD 54 000.
Approximately required budget for full scale operation:  USD 150 000.

In 2008 major expenses were:
Food                                                                                                     USD 9 400
Maintenance/cleaning products                                                            USD 12 694
Vehicles, transport                                                                                USD 3 700
Medication                                                                                           USD 15 840
Wheelchairs, foam, cushion, shoes                                                       USD 10 000
Accommodation, transport, spare parts, hospitalisation fees               USD 8500
Total salary in 2008 approx                                                                  USD 60 000

Average salary health professionals USD 120-140. Technical staff USD 75-100.

Change in staff:

In 2007 approximately staff of 50 persons, in 2009 23 persons. In 2007 maximum capacity of patients 40 beds.  Nursing staff was in 12h shift with 5 nurses on duty daytime and 2 nurses on duty night/weekend/holiday. In 2009 2 nurses are working in 24h shift together. Estimated maximum number of beds 20.

Activity was gradually increasing from 1998 to 2007. During the last year of full scale operation in 2007 a total of 89 new patients were admitted. Level of injury was cervical in 33%, thoracic in 48% and lumbar in 19%. There were 61 male and 28 female patients. Cause of injury was mostly traffic accidents (30%) or fall (33%). Numbers are not available for 2008.

Admission criteria

Even when the center was fully operational Emergency experienced capacity problems and usually referred there patients immediately to the center to avoid unnecessary waiting time before rehabilitation. It is not quite clear how priorities are done today as only a limited number of beds are in use. Admission seems to be regulated by bed capacity at the moment of referral. The center does not give priority to patients with pressure sores and those without family/relative support during their stay at the center. Readmission are kept at a very minimum and there is no routine for follow-up. The center used to have an outreach team, but this service has stopped.

There is no recording of names of patients not admitted to the center. Thus it is not possible to do a follow up regarding outcome of patients with no rehabilitation.

Medical follow up in the center

The center has very clean patient charts with recording of essential medical information including AIS classification. Blood pressure and body temperature is recorded at least once pr day.
On admission patients are usually screened with blood test including hemoglobin, blood count and serology for hepatitis B and C. There are usually no supplementary blood test during the stay. Reports and medical records from the primary treating hospital usually did not follow the patient. Some of the patients had X-ray as documentation; however often of limited value- One female tetraplegic had X-ray of her lower back and pelvis but not of the cervical or thoracic spine.

Urine samples are not routine. X-ray is available in the Battambang provincial hospital. CT can be done in a private institute for about USD 120. Patient will usually have to cover the cost of extra radiological examinations.

Patients have rarely been through surgery in Phnom Penh. One patients with complete injury had months after injury been operated with fixation over 4-5 levels. Their approach was not transpedicular but use of frame and cerclage around pedicles. The patient had been promised ”improvement”, and reported less pain after surgery but no nerurological improvement. The same patient also had MRI pictures of the spine. The costs had been covered by a foreign private financial support.

Nursing

Patients are required to bring one or more family member/relative for assistance. This includes turning the patients every 2 hour if needed. Food is made by family but the center provides rice about ½ kg pr day. There are simple cooking facilities located outside. Previously food was made at the center. Intermittent catheterization is done by latex based catheter with gel lubrication. The catheter will not be replaced before it breaks apart. Patients are supplied with one catheter on discharge and there is no system for replacement. Some patients can get a new catheter from the center even later, and it may be possible to buy catherers by suppliers in the largest cities. Otherwise it is not known how patients manage voiding with catheterization on a long term basis.

Permanent urethral catheter is sometimes in use, as in tetraplegic woman with paresis of unknown cause.

As many of the patients have incomplete or low lesions some sort of voluntary control bladder and bowel function is common.

Use of antibiotics was not common. One patient was on antibiotics for tuberculosis and spondylitis.

Pain was usually treated with acetoaminophen (paracetamol). When needed Tramadol was given as adjuvant pain therapy.

Anticoagulants were given in the acute hospital but due to cost not continued during rehabilitation. They did not have any experience with deep vein thrombosis or pulmonary embolism.

One patient had progressive paresis that started about 6 months ago without any prior accident, infection or other suspected reason. She had been admitted to a local hospital and treated with broad-spectrum antibiotics. Despite treatment she had not improved, on the contrary she had deteriorated. Medical records from examination at local hospital were not available, only X-ray of pelvis and lumbar spine. She had painless movement in the neck. The lesion was now motor complete below thoracic level, but there may be some sensation left. She had an indwelling catheter. Her daughter was there to nurse her.

Little is known about long term outcome. A study based on follow-up of previously admitted patients will probably be difficult due to lack of information about where they live after discharge and no telephone numbers recorded. To have a complete population follow-up study this should be done prospectively. This is also necessary if we are to follow-up patients not admitted to rehabilitation.

Equpiment:

There are harsh conditions for all sorts of equipment in Cambodia: Water, dirt, uneven ground and heat.

Equipment is usually supplied from two sources: Locally made products or donation from charity organizations (see www.freewheelchair.org). The center has received wheelchairs and walkers from charity. The equipment is mass produced in one size with no possibility for adaptation to the individual patient. In experience the quality is very poor, and there are no or very limited possibilities for repayment. The are no cushions or pressure sore preventing system with the wheelchairs.

The locally produced wheelchairs cost about USD 100 and are made in combination of steel and wood. It is delivered in prefabricated parts and can be adapted to the individual. There are spare parts readily available and excellent durability with usually 5-7 years before repair or replacement. Cushions can be made from foam. The use of a single larger front wheel is necessary for a practical use in Cambodian environment.

A tricycle is ideal for ambulation in the local community. The tricycle is locally produced for about USD 150.

The center cover expenses for a single mattress. The cost is about USD 30 excluding cover foam for positioning and pressure ulcer prevention. There is no system for replacement.

Home visit to paraplegic woman

She had a very difficult life for the first 5 years after injury. Her family had to support her in the village. Then she met her husband and married. They have 3 children and 6 years ago the got their own house. The received support from a relief organization to build house USD 300. She had to pay back USD 150 because she had a husband with income (about USD 75 pr month). She expressed fear and uncertainty about the future. Risk of complications and no possibility for medical treatment. The center has been a safety for follow up. Even though her husband worked the family relied on support with 25 kg rice pr month from a wealthy Cambodian paraplegic woman.

Emergency hospital

The medical coordinator had been in charge since august 2008. Decision about transferring patients with brain and spinal cord jnjuries to the provincial hospital had been done before and she was not able to give details about the reasons for this decision. However, it was probably done for capacity reasons rather than the need of resources to these patient groups. Based on previous experiences she would estimate that Emergency used to admit about 2-3 patients with spinal cord injury pr months. As this could be from several provinces it is not possible to make any estimate about incidence. Probably many die one the injury site or before transportation to hospital is possible.

Battambang provincial hospital

In meeting with the vice director we were informed that responsibility for acute treatment of both brain and spinal cord injuries had been transferred from Emergency hospital to them about 2 years ago. He was not able on a short notice to give numbers of spinal cord injuries admitted to the hospital the last year.

We made a visit to the ward that admits injuries. It is a 50 bed unit. At the moment they had a man with incomplete tetraplegia after being hit by a falling tree during windstorm. He had his wife at the hospital and 2 small children at home. X-ray had not demonstrated any significant fractures and the injury was thought to be a medullary contusion. A brief examinatition revealed better motor function in his legs (grade 4) than hands (grade 3). Sensation seemed largely intact and he had voluntary control over bladder and bowel function. He was immobilized and did not have any collar. Despite incomplete injury he still had sustained a sacral pressure sore. The was  no pressure sore prevention and he was lying directly down on a metal frame bed. A blanket was folded up under his back to make it more comfortable. At the time of the visit he was not planned transferred to the spinal unit in Battambang due to reduced capacity, although he obviously would benefit from pressure sore treatment and early mobilisation with a neck collar.

Meeting with authorities in Phnom Penh

Sathia Kim and Rune Nilsen went to see the Secretary of State Sem Sokha. They also met Thoung Vinal from DAC in the same meeting. They were informed about your findings in Battambang.

In our opinion the centre is well planned and with good staff that knows a lot about rehabilitation of spinal cord injury patients. However, there are several challenges: For instance the problem with staff leaving the centre, some problems with toilet facilities and some lack of medicine and equipment. Development of pressure sores is a common complication with life threatening consequences.

They were informed about our intention to establish a professional collaboration between Sunnaas Rehabilitation Hospital in Norway and the centre in Battambang, including possibilities for research projects, staff exchange and some small equipment support.
It was emphasized that we did not intend to take the centre away from the ministry, rather help supporting the professional side and work with the Ministry in their struggle to keep the centre running. In our opinion the center has potential to be Cambodia’s National Centre for rehab of spinal cord injuries. Of more immediate need is improving cooking facilities and physiotherapy and occupational department with new equipment.

It is important to know the difference between rehabilitation of a spinal cord injury patient as compared to an amputee. Explaining that these patients will die very soon if left without proper rehabilitation care, but can live a long life with good quality of life if the rehabilitation system works well.

Sem Socka welcomed the initiative very much and told about the difficult financial situation for the ministry. He also stressed the point of salaries and would most welcome that your program would include incentives for staff. He wanted to make contact with you with the aim of making a MOU between your hospital and the Ministry and looked forward to working with you on this important project.

Possible projects:

1. Programme for pressure ulcer prevention and treatment.
2. Epidemiology. Prospective study – outcome of SCI patients. Discharge 2010.
3. Training in SCI patients. Physiotherapy equipment.
4. Printing information to patients (booklets)
5. Exchange of health personell
6. Support to new equipment: Locally produced wheelchairs, tricycles, mattresses and pressure sore treatment

Dr Chan has considered plans to improve standard for privately paying patients. In Cambodia it is possible to pay extra for a separate room with higher standard. However, the rehabilitation programme is the same as other patients.

Challenges

To develop at comprehensive treatment programme for SCI.
Need of establishing administrative procedures and budget control
Long-term planning and to give priorities when reduced funding
Communication between authorities government/provincial and the center
Communication between center and other hospitals (Battambang, Emergency and institutions like ICRC).

Thomas Glott, June 15th, 2009