Advancing Patient Safety Throughout the Globe: AANA Delegation to Cambodia

By Holly Pham, DNAP-HCA, MSN, CRNA
TxANA Federal Political Director (FPD)
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In April 2023, I had a great opportunity to visit Cambodia. A delegation of CRNAs representing the American Association of Nurse Anesthesiology (AANA), from throughout the United States, including Puerto Rico, met in Phnom Penh, Cambodia. AANA’s past president, Debbie Malina CRNA, DNSc, MBA, FNAP, led our delegation. We visited four different hospitals to learn about their advancements in nurse anesthesia and explored Cambodia's history, culture, and cuisine.  

In Phnom Penh, we visited Calmette Medical Center and Hospital and Soviet Friendship Hospital. Calmette is a tertiary public hospital, and Soviet Friendship is a public hospital managed by the Ministry of Health. At Calmette, we met the chief nurse anesthetist, one of the first nurse anesthetists in Cambodia who is also the current President of the Association of Nurse Anesthetists Cambodia. Two student nurse anesthetists welcomed us and provided great insight into their training advancements.

For several years, the training of nurse anesthetists was at a halt. In the Fall of 2022, training restarted with 97 student nurse anesthetists. Nurse anesthetists do not necessarily make more than other nurses; however, they call it a promotion. It costs about $1,300 per year for their training. According to the International Federation of Nurse Anesthetists, about 70 nurse anesthetists are in Cambodia.

As we toured Calmette, it quickly became a humbling experience. Their triage started outside, where most uninsured are housed and cared for. They are short-staffed and rely on family members to help care for their sick loved ones. Each of their ICU “pods” holds up to six patients. When asked about the nurse-to-patient ratio, they would answer, “the nurses help with all the patients.” Neuromuscular blockade reversal is very expensive and hard to keep in supply. Patients requiring neuromuscular blockade are often kept in the post-operative area until the blockade wears off.

Each of their operating room (OR) suites had newer ventilators, primarily through donation. Advanced airway techniques are skillsets they ask for additional training. Their one and only fiberoptic was broken. They had no working video laryngoscopes, just pieces and parts of several different units. When asked about their difficult airway scenarios, they showed us a box full of laryngeal mask airways (LMAs), intubating LMAs, iGels, and bougies. These are re-cleaned and reused, like many other supplies (circuits, ambu bags, face masks, etc.). 

Our cultural experiences in Phnom Penh included visiting the Tuol Sleng Genocide Museum, the Killing Fields of Choeung Ek, and the Royal Palace. Fun fact, during our stay in Phnom Penh, the King was our neighbor!
The Tuol Sleng Genocide Museum is the memorial site of the S-21 interrogation and detention center of the Khmer Rouge regime. The Killing Fields of Cheung Ek was a place where more than 17,000 civilians were killed and buried in mass graves, many of them transported after detention and torture in Toul Sleng.

We concluded the delegation in Siem Reap, Cambodia, a quick 30-minute flight from Phnom Penh (or a 6-hour drive). In Siem Reap, we visited Angkor Hospital for Children and Neak Tep Hospital. Angkor Hospital for Children (AHC) is solely operated on donations, costing roughly $5 million to run the hospital annually. A donation of $10,000 pays for the annual salary of two nurses. Neak Tep Hospital is a private hospital, utilizing the OR suite about 30 times a month. The nurse anesthetist we met at Neak Tep worked at Calmette previously.

Angkor Hospital for Children’s tour was eye-opening. Their holistic approach to care includes a garden section and a kitchen, where parents learn to grow nutritious produce and cook safely. When a child gets sick, the entire family is also often there. AHC’s triage area (outdoors) is converted into a sleeping area to house these family members at night. They have an outreach program where they travel to rural providences and provide training such as basic first aid and hand hygiene.
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Our cultural experiences in Siem Reap included visiting Satcha, Angkor Night Market, Angkor Wat Temple, Angkor Thom Temple, and Ta Prohm Temple (dubbed the Tomb Raider temple). Satcha is an area of workshops to accommodate artisans and trainees. Our tour of the workshops included stone and wood carving, lacquer, painting, and silk weaving.
After six short nights in Cambodia, many of us returned to the U.S. AANA’s delegation to Cambodia was a humbling yet fun experience. It wouldn’t have been possible without Dr. Malina’s lead and the amazing group of CRNAs, who randomly decided to meet in Cambodia.