Cambodia Blog 2015

January 12, 2016

Hello! We are Lauren and Kristin, two recently qualified Speech and Language Therapists from City University London who have made the decision to fly to Cambodia for 3 months and work with children with cleft lip and palate in various hospitals around the city of Phnom Penh. This is part of the City-Cambodia project which is now in its’ 9th year! Please read our weekly blog to keep up to date with our work and adventures…

WEEK 1: 14th September 2015

So Kristin and I arrived in Phnom Penh on the Tuesday and we stayed in a hostel for a couple of days whilst we found our feet (and a place to live). We also had to get in touch with all the settings to tell them that we were here and ready to start!

The rest of the week was spent in anticipation; we were nervous and excited about starting in our settings. We had only just qualified and this is technically our first job! We also tried to get accustomed to the heat, humidity and hustle and bustle that is Phnom Penh.

WEEK 2: 21st September 2015

We managed to get a tuk-tuk to our first setting which will be visiting every Tuesday – the Childrens Surgical Centre. We got there for 8am and listened to the daily doctors meeting where various cases were presented and discussed. We were particularly interested in the case of an 8 year old girl with cleft lip and palate who was getting a bone graft later that day for the gap in her alveolus.

We met Samnang, the speech advisor for this setting, and Dr Jim, who runs the hospital and everyone was friendly and showed us around. Samnang showed us where his new speech room would be located and also introduced us to a very cute 4 month old who had recently had his cleft lip operation. We toured the rest of the hospital, ending with the staff canteen (extremely important)! We discussed with Samnang how we could help him and he said that he had been asked to present to the doctor’s meeting about ADHD, so this became one of our first aims.

Our next location was the Military Hospital, a large hospital with wide corridors which were easy to get lost in. Our contact here is Dr Nous Sarom, a plastic surgeon with an interest in cleft lip and palate. He welcomed us and gave us a quick tour, showed us the room we could use as our base for Speech and Language Therapy and invited us to watch his consultations that morning. One case was a 5 year old boy with nasal speech despite successful palate surgery (to be continued we think). Later on we watched Dr Sarom perform cleft lip surgery on a 3 month old boy. Thank goodness for air conditioning in the operating theatre! We hope to come to the Military Hospital next week and have someone to train as a speech advisor.

Thursday was a national holiday (Constitution Day), so we don’t get to meet our colleagues at Khmer Soviet Friendship Hospital until next week! Cambodia has a lot of holidays as we are quickly finding out.

On Friday we travelled to National Paediatric Hospital where we sat in on a doctor’s meeting, all in Khmer… Dr Vuthy introduced us to the staff and it was there that we met Dr Vanna, one of the lead surgeons for cleft lip and palate. We will be working with him at the hospital clinic, every Friday morning. Before our clinic started, the speech adviser, Chanthy (also a trained nurse), took us to meet the orthodontic team based at the hospital. They showed us some techniques they use to support feeding in unrepaired cleft lip and palate. We had a busy morning providing speech and feeding advice and carrying out quick assessments alongside the multi-disciplinary team. Some of the patients included a 16 day old baby all the way up to an 11 year old girl. We were thrown in at the deep end but it was very enjoyable.

Next week we are looking forward to becoming more familiar with our speech advisers and our settings, and settling into our life in Phnom Penh.

Your cleft team,

Lauren and Kristin

WEEK 3: 28th September

Lauren and I had a good but busy second week in all of our settings!

Children’s Surgical Center: On Tuesday, we went into Children’s Surgical Center to support our speech adviser, Samnang, in carrying out assessments

with three different clients. We saw one child who had had a Cleft lip and palate repair and two non-cleft clients. Samnang did a great job carrying out the case histories and assessments and made appropriate decisions for each client. One of the non-cleft client’s was a 16-year-old who travelled from a province several hours away and presented with a learning disability. The session was very eye opening and difficult to see firsthand the lack of awareness and education around learning disabilities and communication disorders in Cambodia. To see a teenage girl in our clinic 16 years too late, knowing the impact and difference early intervention could have had on her life since childhood was a tough reality to come face to face with. Samnang shed some light on the situation explaining that many families in Cambodia who have children with special needs accept that their child will be ‘different’ and are often told by doctors from the start that there is nothing that can be done to help their children. As the Cleft settings only work with children who present with Cleft lip or palate, Samnang made the appropriate referral for this girl and another boy who we suspected may have Autism to CCAMH, another setting which two other girls on our team wor

k at and provide input on communication delay and disorders.

Military Hospital: On Wednesday, we returned to Military Hospital where unfortunately we were told no one had yet agreed to work with us as a speech adviser. Fortunately, another doctor at the hospital was able to serve as our translator during the assessment session with a boy we had seen the week before for a surgery consultation with Dr. Nous Sarom. Lauren and I carried out our first proper assessment in which we performed an Oral Motor Examination to check that the boy’s oral structures presented normally followed by a Khmer version of the Cleft speech assessment to determine what sort of speech difficulties he had. We found that his speech was quite hypernasal in which he turned sounds like /p/ into /m/. We suggested he would be a great candidate for therapy once we have a speech adviser; however, mum said the family live four hours away and it is quite difficult to travel so long on a weekly basis. Mum agreed to carry-out some speech exercises with her son at home and to come in for another session in 3 weeks at which time we would observe the progress he made and provide more resources for her to take home.

Smile Cambodia (Khmer Soviet Friendship Hospital): Lauren and I had our first day at Khmer Soviet where we met Dr. Theavy and staff of Smile Cambodia (originally Operation Smile). They told us about the monthly missions at the hospital in which a team based locally or from another country comes for a week to perform a mass amount of Cleft lip and palate surgeries. Our role during the missions will be to provide general speech and language advice for parents prior to their child’s surgery. We are also hoping that during quiet, non-mission w

eeks we will be able to see past patients who had a successful surgery in a previous mission and are able to attend some therapy sessions at Khmer Soviet. Like Military Hospital though, we are still in need of a speech adviser who we can train to provide this service. Dr. Nous Sarom expressed a keen interest in building a speech program at the hospital so we are hopeful that we will find a few dedicated speech advisers to help us make the service more sustainable.

National Pediatric Hospital: The Friday morning clinic was as busy as ever with 10 clients seen within 3 hours. The youngest client was just a few weeks old and the oldest client was 25! Our speech adviser, Chanthy, was extremely helpful in providing advice to parents with us. Throughout the morning, we were faced with some challenging situations. One mother came in with her daughter who presented with Cleft lip and palate as well as Down’s syndrome. Once again, it was hard to realize the lack of awareness around learning disability and the stigma which surrounds it. However, mum was keen to understand ways in which to support her daughter and we spent quite some time providing education and strategies to support her daughter at home. Though the family lives quite far away, mum agreed to attend an appointment at CCAMH where they would be better equipped to further assess her daughter’s needs and provide additional advice.

Lauren and I also found it challenging to provide advice for the 25-year-old woman who came in looking for help with her speech. As she was not able to have her Cleft lip and palate surgery until her 20s, she had mislearned how to produce speech sounds through her nose rather than her mouth. We provided as much feedback and self-practice as possible, but again she lived hours away from Phnom Penh where there is no one to provide speech and language services. After clinic, we spent an hour with Chanthy and Dr. Sophen, a general practitioner, training them in the basics of speech, language and communication. This was the first of 10 training sessions we will have with Chanthy and Dr. Sophen as they are keen to support children with speech and language difficulties in their practice as a nurse and doctor. The training session went really well and we are looking forward to working with them for the next 9 weeks!

This past week definitely had its fair share of challenges. We are beginning to realize just how much need there is for awareness and education on learning disabilities and communication disorders and the lack of support services available throughout Cambodia. However, we are glad to be working with individuals who are passionate about gaining knowledge and spreading awareness about such issues and the benefits of speech and language therapy!

Your Cleft team,

Kristin and Lauren

WEEK NINE: 9th -13th of November

So it has been another busy week! We can’t quite believe it is Week 9 already.

On Monday we had a meeting with our Khmer friend Thyda, who works in an International school, to discuss raising awareness of Speech and Language Therapy in her school. We will be preparing a presentation for parents and teachers in English and then Thyda will hopefully be our interpreter on the day. This is an exciting prospect as we are always looking to get the word out about Speech and Language Therapy and how it can help children and adults, not just those with cleft. We also had another meeting with a representative from Smile Train who are an organisation helping to fund cleft surgeries in countries all over the world, including Cambodia. We wanted to try and get funding for a Speech Adviser in some of our other cleft settings so we chatted to him over dinner, along with Dr Nous Sarom, a surgeon from Military Hospital. We are finding it difficult to work at Military Hospital at the moment due to the lack of a consistent Speech Adviser. We hope to get someone to train in the next few weeks so that they feel confident working independently when we leave. This is still up in the air at the moment so we will keep you updated. They did however say that they are happy to get the Smile Train feeding video we found translated into Khmer, so this is small step forward! We hope to get one of our Speech Advisers to provide the voiceover.

On Tuesday morning we visited All Ears Cambodia, an NGO which provides free hearing tests and ear care to people in Phnom Penh. As children with Cleft Lip and Palate very often have associated hearing difficulties, this was a great chance to see where we are referring our patients. We met with Ned, a British audiologist who is head of the training at All Ears. Every two years they take on 10 new Khmer trainee audiologists and help them gain a new profession. We were very impressed by the set-up and we hope to the see the same sort of training for Speech and Language Therapists in Cambodia one day. The afternoon brought us CSC and time with our Speech Adviser Samnang. Unfortunately there were no patients for us to see and this is happening quite regularly so we had a chat with him about how we could organise the way he sees patients. Tim Pring, who started the City-Cambodia Project, came out with us to CSC and wanted to speak to Dr Jim, the founder of the hospital. We had a meeting with them all and we gave Samnang a target of finding at least 10 cleft patients for us to see in our last two weeks at the hospital! (Samnang is at a cleft conference next week and it is Water Festival the week afterwards, so time is running out!)

Wednesday morning was the first Non-Cleft clinic at NPH with Dr Alin. She is growing more and more confident in her skills and is already calling herself a Speech Therapist after her 3 months training in Taiwan. Although she is brilliant at providing speech and feeding advice for cleft clients, she hasn’t had much experience in providing language advice or therapy for children without cleft. The normal protocol would be to refer these on but now she wants expand her skills which is great. We saw about 5 children and informally trained Dr Alin on some basic language assessment. We think it is a great idea to separate the cleft and non-cleft but it is just a matter of making this clear to the patients, who seem to turn up whenever they like!

On Thursday afternoon we went to see Samnang again but unfortunately he was ill. We saw the twins again and gave advice for a little girl who had just had her palate operation. The twins have obviously been practicing a lot, as despite not coming to therapy for the last two weeks, they have improved a lot. This was great news as often parents come to us for a quick fix for their child’s speech, but this Mum seems very motivated and makes sure her children do their homework! Ramaniya, an eye doctor came to help us when giving advice and therapy, as we needed someone to translate for us. We still haven’t learnt much Khmer apart from numbers one to five, ‘mouth’ and ‘nose’! Although it was helpful to have a translator, it is even better when Samnang is here because he can improve his skills as a speech adviser and translate for us at the same time.

Friday was a busy day like always and we saw about 20 patients between us at the National Paediatric Hospital. It was great to work with Dr. Alin again because we don’t have much time left with her. We also saw the patient’s quicker than usual because we could split up and give advice; one of us working with Chanthy and one working with Dr Alin. Maybe Dr Alin could use her skills to train Chanthy in the future but we will see how this goes. NPH is so busy and it would be great to see the other hospitals having a clinic like this – an aim for future City-Cambodia Cleft teams I think! In the afternoon we saw Chanthy, Dr Alin and all the staff at One-to-One again to give training. This time it was about assessing children’s speech and language and we tested everyone’s discrimination of speech sounds, with mixed results! We have one more training session to do next week and then it is Water Festival and everyone in Phnom Penh has a week off.

We’re 9 weeks in with 4 more to go!

Your cleft team,

Lauren and Kristin

WEEKS 10-12: 16th November-4th December

It’s been awhile since our last post! During week 10, many of the surgeons and speech advisers from our settings attended a cleft lip and palate conference in Thailand and during week 11, Cambodia celebrated Water Festival so our clinics were closed. Though these two weeks were quite slow with work, things picked up in week 12 and we were as busy as ever!

On Monday, we spent our admin day visiting the other settings where our other colleagues involved in the project work. First, we checked out the Rabbit School where Sam and Shona work. The Rabbit School is a school for children with special needs including Autism spectrum disorder, Down’s syndrome, and learning disability. Following this visit, we went to the Children’s Centre for Adolescent and Mental Health (CCAMH) where Kim works. This centre focuses largely on multi-disciplinary care for children with Autism. It was great to visit this setting as Lauren and I often refer non-cleft clients seen at the clinic for suspected Autism and learning disabilities to CCAMH. The opportunity to visit the other settings gave us the full picture of the positive impact we are making to spread support and awareness for several areas of SLT in Cambodia!

On Tuesday, we spent a full day at Children’s Surgical Centre with our speech adviser, Samnang. Samnang did a great job following through on his promise to book in a substantial amount of clients. The day was non-stop with the twin boys being seen for a therapy session in the morning and three assessment and advice sessions with cleft clients in the afternoon. Additionally, we invited a speech adviser in training from Khmer Soviet Friendship Hospital to begin her training that afternoon. As Samnang now has 8 years of experience as a speech adviser with our project, we thought this would give him the opportunity to share his knowledge and develop skills in others to become speech advisers. It worked out perfectly since we have just recently secured a speech adviser at Khmer Soviet but are near the end of our 3 months here. It was great to watch Samnang work with the clients and train the speech adviser at the same time. He seemed very confident and was excited to be the teacher rather than the student. We even got to watch him use his ENT skills when he carried out a nasendoscopy on one cleft client who expressed concerns of difficulty breathing. After watching Samnang in action, we are confident that he will be able to train the new speech adviser independently after we have left.

On Wednesday, we supported Alin in the morning clinic at National Paediatric Hospital. Now that Alin is back from Taiwan, she is providing SLT services to non-cleft clients on Wednesdays in addition to the Friday cleft clinics. As Alin is keen to become a qualified SLT, we think this is an excellent opportunity for her to broaden her skills in the field beyond cleft lip and palate. Though the clinic is meant to be primarily for non-cleft cases, we still saw quite a few cleft kiddies! But that’s OK because the important thing is that the clients are aware SLT services are available! Since the bulk of Alin’s experience is with speech and feeding advice for cleft clients, we have started developing her skills in assessment and advice for language delay and disorder. In doing so, we worked with Alin to create a basic language assessment known as the Derbyshire Language Scheme which assesses a child’s ability to understand directions at different levels of complexity.

Alin training a cleft client on how to practice using oral sounds with the use of a tube. When producing oral sounds into the tube, the client should be able to feel the air reach ear. If the air doesn’t reach the ear, this is a sign that the client is using nasal sounds rather than oral sounds. This is an effective tool for providing feedback to the client.

As time was limited on Wednesday, we met with Alin again on Thursday morning and we completed the language assessment together. She offered great ideas and grasped the concept of the assessment quite quickly! We plan to do a role play this week with the assessment so that she can learn how to administer it and feel competent doing so. During our Thursday meeting, we also helped Alin to create a budget for her cleft services. The organisation which sponsored Alin to go to Taiwan has agreed to provide Alin with some funding in order to set-up a 5-day clinic at NPH for cleft clients. She will continue to provide SLT services on Wednesday and Friday, and on the other days she will take on her doctor role in providing care and management to the cleft clients. We are very excited that Alin will have some funding to build up the SLT services at NPH and look forward to seeing the developments of the clinic!

On Friday, we went back to NPH for the morning clinic. It was a pretty crazy morning because our other speech adviser, Chanthy, and Dr. Vanna were absent leaving just Alin, Lauren and me to see over 20 clients in the space of 3 hours. But Alin handled it like a pro and we managed to see all of the clients! That afternoon, the three of us met with Betsy, a visiting Speech and Language Therapist from the USA. She comes to Phnom Penh for about 9 weeks at a time every few months to provide SLT input for the adult population. Betsy is one of the only SLTs providing support for adults with communication and swallowing disorders in Cambodia so her work is very important! She spends most of her time training physical therapists in communication strategies for stroke clients and trains surgeons and doctors in FEES, Fiberoptic Endoscopic Evaluation of Swallowing. This January, she will hold a 4-week training course in this procedure to advance the skills of surgeons and doctors here in order to become competent with the use of this assessment tool in order to evaluate swallowing difficulties in adult clients. Even more exciting, Susan Langmore, the inventor of FEES, will provide this training with Betsy and offer her expertise in the field to further support services in Cambodia! Very exciting stuff! We were glad Alin had the opportunity to meet with another SLT who works with a different population outside of cleft so that she could begin expanding her professional network!

A very busy day in the cleft clinic with Alin!

Our second to last week in Cambodia sure was full-on and eventful! We are hoping our last week here will be as well. We can’t believe we will be leaving Cambodia in just a few days. It is crazy to think how fast time flew by! We are so thankful to have had the opportunity to develop our field in a country where it is essentially non-existent and hope to be back one day soon!

Stay tuned for our final post coming soon!

Your cleft team,

Kristin and Lauren 

CAMBODIA WEEK 13

So we’ve done it! We’ve worked out in Phnom Penh for 12 weeks now (3 months!) and this week was our last. The final hurrah.

Monday and Thursday, our admin days this week were spent report-writing for each of the settings and drawing our work to a close. It is really difficult to summarise our work into a few pages of a report but we tried! Although we both love the hands on Speech and Language Therapy work, we know that it is important to keep good records so that these can be passed on to the next cohort of Speech and Language Therapists who go to Cambodia. Hopefully our work can continue where we left off.

On Tuesday we went to say goodbye to our Speech Advisor Samnang and our Speech Advisor in-training Srey Lak at Children’s Surgical Centre. It is great that Samnang has someone to pass on his skills too – the further we spread the word about Speech and Language Therapy, the better. Srey Lak will shadow and learn from Samnang on Tuesday afternoons until she feels confident enough to work on her own at Khmer Soviet Friendship Hospital. She is a trained midwife and full of enthusiasm for her new role. It is such good news as well that these two hospitals are willing to learn from each other and communicate as this was unheard of a few years ago. We had a second session with a boy we saw a few weeks ago with lots of sound substitutions in his speech making it difficult for him to be understood. We did some further assessment and with Samnang we decided on sounds to target with him in therapy. He has agreed to come regularly for therapy which is another success story! The twins were ill today but we also saw Samnang give advice to the parents of several young patients in the wards about post-op care and feeding. Samnang is using his leaflets wisely and we gave him more copies to start giving out. We ate lunch with Samnang as a special goodbye and also said goodbye to other staff we know at the hospital.

On Wednesday we saw Dr Alin at the National Paediatric Hospital (NPH) to help with her non-cleft caseload. Inevitably there were some cleft cases but this always tends to be the case. There were a few cases we referred to CCAMH (Centre for Child and Adolescent Mental Health) and a few that Dr Alin would like to see for therapy in her clinic. This week we saw the new clinic room being decorated along the corridor. This is exciting and the future at NPH for cleft and non-cleft patients alike looks very bright!

 

Friday brought us back to NPH for the final time and with it, so many babies! We saw Chanthy again, our Speech Advisor who works with Dr Alin now at the Friday clinics. She is hoping to stay working on Fridays until she has her baby next year and she is so confident now at giving advice for feeding and speech difficulties. This week we worked with Chanthy to train her in using the KASS (Khmer Assessment of Speech Sounds) which helps us to decide which speech sounds a child struggles with and which to target in therapy. She found it difficult to listen for the sounds at first but it takes practice. We found this one of the most difficult things to learn when we didn’t really know the language! The assessment involves asking the child to name pictures and writing down how they say them. As we have used this assessment a lot, we now know lots of weird and wonderful Khmer words such as ‘grapes’ (‘dom-be-an-buy-chew’) and ‘hammer’ (‘nya-new-ah’). It was great working with Dr Alin as well and she saw the young lady we brought in for a second opinion about her secondary palate surgery from another hospital. She now has to decide whether to have the surgery or not. A whirlwind day as always.

It is so sad to write this final blog post and even sadder to leave everyone in Phnom Penh who continue to work tirelessly for children with Cleft Lip and Palate. We look forward to returning to Cambodia in the future and using our new found skills in jobs in the UK or USA.

Shout out to all our Speech Advisors – Samnang, Dr Alin, Chanthy and Srey Lak – we wish you the best of luck in 2016 and we hope that you are around next September!

Goodbye and Good Luck! (‘Nee-hi’ and ‘Samnang la-or’)

Your cleft team signing off,

Lauren and Kristin