In places like Cambodia, primitive conditions and the lack of funds leave little hope for adequate care

Fifty-five-year-old S.O.’s fingers fidget aimlessly over the ubiquitous khmer shawl popularized during the infamous Pol Pot regime. He removes it to reveal his left thigh—or what’s left of it—barely 10 inches, a withered, thin stump.

But that’s not what he came to the hospital for. It’s his other leg, and he wants it cut off.

His story started in 1983, as a Red Khmer soldier in one of the last bastions of their hardened army, Anlong Veng. The town held out until 1996, but Mr O. had no part in the defense anymore.

“I was leading my platoon under heavy fire,” he explains. “The entire area was heavily mined. I was well aware of the danger. Then it happened. I heard a loud bang followed by a deadly silence. As I came to, I yelled, ‘Take cover! Anybody hurt?’ The men looked at me strangely, in silence, and I realized it was me.

“A medic cut my left leg off, straight, with a saw. One of my men punched me in the face to put me out, but that didn’t work.”

The left leg healed spontaneously over the next few weeks, but the right one never did. Mr O. entered the frustrating tedium of wound healing in poor tropical countries.

The initial trauma to his right shin exposed his fractured tibia, tendons, and muscles, with the usual foreign bodies embedded as well—debris of soil and plants, and perhaps some fragments from his shredded other leg. Medics in the Khmer Rouge army would not be trained to address these issues. The “natural” healers, however, would draw from a treasure trove of eons of accumulated verbal knowledge about herbs and biological remedies.

The Natural Healer
Eighty-one-year-old L.N., a still vigorous man with long, flying white hair framing his dark, round face and his equally white beard knotted neatly under his chin, graciously shares the intricacies of his profession, called “kruh khmer” in Cambodian.

“First of all, we would evaluate fresh wounds for fractures and contamination,” he says. “One of the initial therapies would be the application of tobacco, particularly to bleeding wounds, followed by a compression bandage. Usually, 10 to 15 minutes would be enough. Then, we would remove all tobacco, debris, and gross contamination with boiled water fortified with antibacterially active herbs.”

“Tamarind leaves are an essential part,” Mr N. responds when quizzed about particular herbs. “The dried tobacco has a distinct anesthetic effect on the wound already, but now we are concerned with bacterial contamination. Here our main ally is ‘muk chneang’ [Pouzolzia zeylanica (L) Benn, a ubiquitous product in all Southeast Asian herbal markets].

“Not all of these plants are equally effective, so we have to test it for its potency. We boil it in water and apply it to rotten meat or fish paste. If it drives out the maggots, it is strong enough. Then, we pour the mixture, augmented with some other herbs, into the wound.”

To a question about the use of maggots in chronic ulcers, a treatment that has recently gained popularity in Western medicine, Mr N. replies, “We don’t look at maggots as anything particularly helpful. We make an effort to remove them without killing them. We never saw a beneficial effect.”

“I would know when maggots got into my wound,” concurs Mr O. back at the hospital. “It would hurt and burn very badly. Once I got rid of them I would feel better.”

Questioned about using dressings versus leaving the wound exposed, the herbalist explains: “We always apply compression dressings to fresh wounds. Often, we have to resort to pieces of cloth or linen. We change the dressings frequently, at least once every other day, to clean and apply fresh herbal medicine. If a wound refuses to heal, we tend to leave it open, but apply a paste with garlic to the surrounding skin. Garlic is our main weapon against flies and insects, even with small, fresh cuts. However, don’t let it get into the wound!”

Other patients agree. “Without garlic, we would have swarms of flies and ants populating cuts and sores.”

Hostile Environment
The living conditions in tropical villages and jungles of poor countries often lead to complex injuries with open fractures and considerable skin loss. Animal husbandry, hunting, wood cutting, clearing in rough terrain, and transportation of huge, unsecured loads are constant threats that are complicated by the absence of lighting and electricity. Even the simple trip to the latrine at night can be a hazardous undertaking. Pointed branches, muddy footpaths, and poisonous creatures can easily inflict serious injuries.

People tend to resort to self-help in an economy in which even a fee of 25 cents for the natural healer puts a dent into the family’s budget.

“Open fractures require a different type of treatment,” declares Mr N. “Here, we have to use animal products. Burnt elephant and tiger bones, as well as other animal parts, are mixed with boiled animal fat into a sterile paste that is placed deep into the wound. Of course, we have to stabilize the fractures with compound splints of wood branches and bandages. When explosions are involved, we debride the area as well as possible.”

He adds, “The observation of nature leads us to select certain animals as promising for therapy, such as a small wild goat that heals its own fractures rapidly by just licking the injury. We try different parts of the creature, such as horns, skin, or bones.”

On the question of using fresh animal tissues, he tends to differ with other healers. “First of all, as Buddhists, we try to refrain from taking any life for any purpose. Second, we are afraid of introducing poison or contamination with fresh tissue. Also, we think it is unhygienic to chew plants before applying them to wounds, as some practitioners like to do.”

All the traditional therapy efforts had no discernible impact on Mr O.’s leg. The ulcer continued to fester over the next 23 years and kept him from walking. The only improvement in quality of life came 1 year ago in the form of a donated wheelchair. Before that, he had to crawl along the floor, even out in the rice fields. In the end, he felt he would be better off with no legs at all.

Frustrated Physician
Rada Doung, MD, a surgeon at the Siem Reap Provincial Hospital, shakes his head in frustration as he opens the latest dressing covering the ulcer. “It doesn’t look good,” he mutters under his breath. “Do you smell the odor?” Indeed, the pungent aroma of Staphylococcus aureus fills the air, ever more noticeable with each layer of gauze removed. Finally, the disheartening remnants of a necrotic skin graft signal the failure of yet another attempt to undo the ravages of 23 years of festering chronicity.

“What shall we do now?” the physician asks with an expression of helpless resignation. “Is there any way to save the leg?”

Perhaps a muscle flap may be the answer, but the soleus and gastrocnemius look pitifully thin. Perhaps a consultation with a foreign plastic surgeon may produce some different ideas. Unfortunately, there is not much in these operating rooms that a Western surgeon would need to perform a complicated repair. Whatever the treatment may be, it will be subject to an incredibly tough environment once the patient returns to his village.

Therefore, in poor countries such as Cambodia, a Western surgeon may have to rethink his approach to wound care. The following considerations must be taken into account:

• A patient will rarely come back for a follow-up, so most often there is only one chance for treatment. Therefore, the treatment has to be definitive, no matter how complicated the injury.

• Primary closure without excisional debridement often leads to failure. Even seemingly clean wounds coming out of fresh or ocean water may harbor massive loads of germs. After the tsunami in southern Thailand, almost 90% of primary closures had to be reopened and drained.

• Leaving repairs exposed increases the risk of infection dramatically. Flies and insects in poor countries carry dangerous loads of bacteria.

• Natural healers’ methods may prove useful in many instances. For instance, the smell of garlic may not be quite as offensive in tropical villages if it keeps the flies away.

• A careful history must take all prior traditional medical attempts into account. There may be a surprise waiting at the bottom of the wound.

• The aggressive use of skin grafts can forestall poor healing.

• The scalp is probably the ideal donor site in poor countries for the reasons given in the box on this page.

• Open fractures may call for the early use of muscle flaps. Chronic infections in other locations can often metastasize into recent areas of trauma.

TB From an Injured Knee
Take the case of 29-year-old C.S. Two years before his admission, he bumped into a blunt object on his farm, causing some swelling above his knee.

“There was no reason for concern,” he remembers as he stares at his emaciated leg. “It had happened before. But then the swelling would not go away. Instead, the pain would get worse and worse, and my knee would swell up as well. Soon I couldn’t walk on that leg anymore.”

He massages his leg with a hand that also carries the scars of a bad event. “Fishing,” he explains tersely when prodded for the cause of the missing parts. “It happens a lot in our village.”

Fishing? Are there sharks in the rivers? “We would use a lighter to set fire to the fuse on a grenade or landmine before we throw it into the water,” the patient chuckles. “Sometimes they went off early. My hand just healed by itself, with some help from the traditional healer. As for my leg, the healer would try many things, to no avail. Now I can’t move my knee at all anymore.”

The Scalp As A Donor Site
• The thickness of the skin allows multiple harvests within a short period of time.

• A somewhat skilled surgeon can take a graft even without a dermatome with a No 10 or No 20 blade.

• The abundance of follicles and sweat glands promotes fast healing.

• Excellent circulation minimizes infection.

• The paler color matches recipient areas better, particularly in individuals with pigmented skin.

• The donor site is concealed once the hair grows back.

• Postoperative pain is minimized because of the location away from mechanical stresses.

Indeed, his knee is fixed in a 45° angle. When asked about an incisional wound above the knee, surgeon Samon Thou, MD, reveals the unfortunate nature of this injury. “We drained an abscess when he came in. It’s tuberculosis. After the incision, he started to develop fistulae in his lower leg. I am afraid we may not be able to restore the knee even if we cure his TB.”

Like so many poor farmers in this country, Mr S. suffers from pulmonary TB. The post-traumatic hematoma served as an initial breeding ground for that infection, only to spread into his knee joint as well.

“We will ask a Western specialist what we should do,” Thou says. “I hope he will understand our lack of so many things.”

A Desperate Need
Yes, there is a desperate need for “so many things” in a country where the average income is less than $300 per year. Subsistence farmers may be able to raise the fare of a few dollars to the hospital by mortgaging their farm. Then there is nothing left: not for diagnosis, not for treatment, not even for the fare back.

The old soldier, Mr O., can consider himself lucky. His ulcer hasn’t turned malignant yet. Others are not quite as fortunate. It’s not unusual to see large tumors originating from these chronic wounds, often metastasized far beyond the lymph nodes. Those patients will go home, somewhat poorer for the trip, and die. Their children will fall into indentured servitude, or, if they are lucky, wind up in an orphanage that we are so happy to support with US dollars.

In the final analysis, education and assistance in managing complicated cases goes only so far in the face of grinding poverty. Perhaps a charitable fund to support treatment for the indigent may help to bridge the ever-widening health gap between the poor and rich nations. Hospitals can’t function well without fees, and physicians’ monthly government incomes of $50 or less don’t promote extra dedication. The price of one dinner in America can be the difference between life, disability, or death for one poor worker overseas.

Gunther Hintz, MD, is president and CEO of Medicorps, and a contributing writer for Plastic Surgery Products. He can be reached at [email protected].