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Last spring, I had the incredible opportunity of being able to take, transfer and apply my skills of scar massage to a setting that is worlds apart and different from any reality I have encountered or experienced before.


September 30, 2009
By Anna Kania

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Last spring, I had the incredible opportunity of being able to take, transfer and apply my skills of scar massage to a setting that is worlds apart and different from any reality I have encountered or experienced before.

cambodia-main.jpg In May 2005, I took a three-month leave of absence from my job as a Registered Massage Therapist at St. John’s Rehab Hospital (in Toronto Canada) and traveled to Cambodia where I worked in an NGO hospital (Children’s Surgical Hospital) providing and teaching scar massage which would be applied in the post-operative treatment of acid burn victims and other burn survivors  (from accidents around open fires). It was an experience that has impacted me in various ways, both personally and professionally.

On a professional level, it made me realize the very real therapeutic benefits of the scar massage intervention and the incredible contribution that one can make when they get their hands in their – literally and figuratively!

During my time in Cambodia, I kept a travel journal in the form of a blog. As noted in the blog, I wasn’t sure what I would be writing about, but the process of writing, in of itself, makes me stop long enough to at least consider, digest and contemplate what is happening around me. On the following pages are a few excerpts, directly related to my experience as a clinician, a health care professional, a Massage Therapist, and a regular person.

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C-temple-boats.jpgPictures Come To Life … Saturday, May 14, 2005
I have seen pictures of Cambodia, but now it’s three dimensional. It’s REAL, I can’t turn it off … I don’t want to turn it off. These people are real – I can see them dusty on their mopeds, or through the holes in the walls of their homes. Their smiles are warm, their eyes are big, shy, and very penetrating. They are curious but soft in their curiosity – I feel I am invading their space. I am quickly taking on their body language – bowing every time you say thank you, voice becomes a little softer. I feel that every time I step out I sink a little deeper into my new surroundings …

I went to CSC (Children’s Surgical Center) with the Physical Therapist, Mr. Ath, for about 15 minutes when I arrived here to get a sense of it (Mr. Ath is away for four weeks on a mission with the army and I am being handed the keys to the physical therapy room). As he is away there is not physiotherapy for that time. I hope I can be of help (idea seems to be liked).

Driving across the Japanese bridge, surrounded by mopeds that have two or three people on them, riding in streets that have congested traffic, we turn right onto the dirt road that leads to CSC. Again, I recognized it from pictures, but it breathes, it has its own presence, a lightness of sorts created by the whispers and breathing of its patients. It has a sense of peace, too, I think I have always felt and appreciated this about hospitals – as it is a place where people are safe because they are being looked after. There were not very many patients there because it is the weekend and there is no surgery on the weekends.

In one main room there are three patients with their families sitting about their beds. In the next room, slightly smaller, there are two burn victims – a man and a woman. One was an extensive burn – face, torso, limbs. There was a little girl sitting by her, waving a makeshift fan over her face from time to time. I was nervous at first because her injuries were so extensive and her face was completely altered from the burn, but when she spoke to tell us that the third patient was out for a walk, my nervous melted and suddenly I just wanted to help. She is a human being. That’s all I saw.

The other patient, a man was lying on his side, sleeping I think. It was hot. It was very hot in the room. I cannot imagine how they were tolerating their injuries and the pain, in this heat with minimal pain killers, suffering in silence. I imagine after a while you just do not have the energy to express the suffering one feels.

C-anna-stretching-arm.jpgObserving, Absorbing … Wednesday, May 15, 2005
The brown iodine mixture that is put on wounds mixes with the lotion I use to massage the scars. It makes a funny yellow colour that reminds me of runny mustard. 

The tissues (scars, skin, and muscles) are very human but there is one distinct difference – I feel much more bones because there is much less fat. The scars are much thicker and the contractures severe. The deformities, none like I have ever seen before.

But the tissues and scars and people respond to my hands, to the massage. The scars begin to move, become more mobile. Limbs begin to move.

There is less discomfort in the patient’s eyes.There is a very specific smell in the air. A smell that is common here because it is mix of food, bodies, urine under the bed, and open wounds. It is a pungent smell to me – one that I neither like nor find disgusting. But it is a smell that I know I will become used to – and next week I will not smell it anymore.

My eyes are not used to the fact that there are no IVs or multiple bottles of medicines by the patient’s beds.

Families of patients continuously migrate from one bed to another, or one room to another, to observe what is being done to patients. They don’t say very much, just look. My new roommate explained that that is part of the shock the country is still after the atrocities the population here suffered – in the face of something tragic people simply stare. Their gazes follow me as I travel from one room and another. Their faces are serious, their eyes dark and intense but when I smile and say hello, they break out into the most beautiful warm smiles and laughs. I guess sometimes that is all it takes.

C-anna-with-lady.jpgOn The Edge Of Violence … Tuesday, June 14, 2005
The acid burns and the entire culture of their occurrence is shocking me. I ingest it piece by piece. I can only take in pieces at this point because I find it disturbing in a way that leaves me stunned and at a mental crossroads. I hit points of saturation daily; at which point I need to mentally switch gears or walk away for a breath of something else because otherwise I become ineffective and get swallowed up by various thoughts and emotions that would not have any immediate benefit to anyone – the staff, the patients or me.

I’m not sure how prevalent or common acid attacks are. The statistics are varied and generally not very reliable.

To clarify – acid attacks are the intentional act of pouring acid on a person to cause them harm. Although they are a criminal act, it is not common for the acid burn victims to take their assailant to court. Talking to the acid burn survivors (through translators such as the nurses) and reading assessment questionnaires from the Acid Burn Survivors Support Group (ABSSG) here at CSC, I begin to learn pieces of stories of these individuals. Personal stories that give a human face to impersonal statistics or numbers.

I often travel between two worlds – the one I can relate to and the one whose realities I am beginning to grasp: I cannot imagine pouring acid as a way of dealing with marital problems or problems in general.

At which point does an individual cross over and become capable of this type of violence? To a person with whom you share a home? With whom you have created children? Where is this type of brutality born out of?

As I write this, it feels surreal. However, when I leave this computer and massage the extensive, deforming, life-altering scars caused by the acid which had burned its way through flesh and muscle, it is very real. I feel with and in my hands, I smell the scars, I see the eyes of these patients as they struggle to move on in their own ways.

And it goes on … the scars are so extensive and the damage so deep. There is little to no social support for these individuals. Many have their families, which will support them. Many do not – those will end up living out their days making money off their scars and deformities as beggars … enough money for one meal a day of rice and maybe some fish and vegetables.

The Khmer people are kind. They are soft. They do not act or carry themselves in an aggressive manner. At least that is the perception of this female  foreigner. But there is an underlying edge here, a potential for violence that exists within. I think they are not inherently violent or aggressive – humans are not born to kill or hurt.

We are taught the violence. Hence this edge of violence maybe a result of the violence that on a social scale these people have experienced and endured. Oppression, suppression, poverty and years of bloodshed – the social wounds and scars leave their marks on generations and surface in various ways.

C-7-year-old-burn.jpgFull Circle … Tuesday, June 4, 2005
The operating room is very cool and smells very sterile. It is a potent smell – a little like Vicks VapoRub, but with less peppermint. The patient, a little boy, lies on the operating table. A group surrounds the table – three physicians, two assistants, one nurse observing and myself (observing as well, although I must admit I wanted to get my hands in there too!). The surgery was a release surgery of the left hip and right foot.

The little boy sustained extensive burns to the front of his body (face, torso, right arm and hand and both legs on the front) about four years ago. The scar growing into a thick mass.

As the wound closed after the burn, the scar that formed began to pull the edges together, causing contracturing at the hip, the left hand, and both feet such that the toes on both feet and fingers on the left hand were literally pulled backwards of the top of the hand and feet. On the ears and the left mandible, the wounds developed into massive keloid scars. This was the second surgery – a release surgery which is done to release the scar and the joints can be moved back into proper position.

Back to the operating room … I walked in towards the end of the hip release part of the surgery. The doctors where preparing to cut through the solid mass of scar tissue on the foot.

First, discussion about the incisions – direction, depth, how many to make along the longitudinal lines. The boy’s head and torso is covered. Only the leg is exposed. They move the leg about in all directions, examining,

considering. There is no resistance from the boy … I’m intrigued as I’ve never worked with such a limp body – I’m used to the body responding, moving, resisting, releasing or contracting in response to what I do to it. Here, there is not resistance or response – it seems much more malleable … there is not personality to that leg, no sensation to guide you … only the pure anatomy dictates what must be done.

The discussion ends, the scalpel is passed from one set of hands to another and the first incision is made. At first I feel my pulse rise as the scalpel enters the flesh, but that quickly passes and I lean in a little closer. I’m surprised at how little blood there is … one of the medical students is ready with a bloody gauze to clean up and absorb up the blood that does bubble up to the surface. The skin splits and gives away quickly from the tension of the scar. The white of the underlying fascia and tendons becomes visible. The doctor releases the adhered scar from the underlying tissue with an instrument he inserts under the scar and pulls up, tearing it away from the underlying tissues. I’m amazed that no muscle was cut, no tendons nicked or damaged.

The incisions are made in a Z-pattern along the dorsal surface of the foot and quick, efficient movements sew the opening up. Large needles are inserted into the toes to stabilize the toe joints … how quickly and easily they go in.

I wonder what type of resistance the tissue gives to the needles? What the doctor senses as he pushes deeper to guide him and ensure the needle is not damaging any bones or blood vessels …? The toes are so small and his hands so large. I’m amazed at how steady his hand is.

In surgery you literally open the body up and look inside; I spend my days “looking inside” with my hands. It was amazing. I feel like I’ve gone full circle: in the surgery room I saw the layers, the colour, the thickness of the scar.

When I look and touch now, there is a whole new dimension to my understanding of what I am palpating. Now it’s more tangible for my mind to capture what my hands sense …

C-at-table-eating.jpgA Tender Moment … Saturday, July 9, 2005
She is the only acid burn patient currently at ROSE. She arrived one week ago. I first saw her during rounds sitting in the main ward, her face charred and hardened pus on her chin. Her eyes were shut from the scars. There are some splatters of acid on her left shoulder and left hand, but most of the damage is to her face and ears. She will undergo debridement (removal of the dead skin) and then skin grafting on her face because the scars are too big and too deep.

Her mother and her husband are with her. Her mother’s emotions are effectively covered by her constant smile. Her husband looks sad and exhausted. He sits by her bed, looking at her bandaged face – only slivers for her eyes, mouth and nose. Sometimes he holds her hand. Whenever I walk into the room he quickly walks away and sits in one of the corners. I realize I have never heard his voice. I am mostly aware of his eyes (they always looking puffy, as if he’d been crying) and his tattoos – the ones that men get here to keep bad spirits away. I haven’t seen these many on one body before.

As I’m treating Chan, he watches. And then he picks up his wife’s burned hand and begins to massage it, mimicking what I did. He’s shaking a little bit. I feel a little bit like uncomfortable watching this tender moment from afar. I walk over and sit beside him. He quickly gives me her hand but I don’t take it. Instead I place my hand over his, and guide his hand as it touches her skin and then begins to move closer to the scars, gliding over the scars, moving into the scars. His hand is soft and picks up what I am doing quickly. I smile and nod and he smiles back. All of this in silence … not one word was exchanged.

Five days after the operation, dressing changes begin. It’s an incredibly painful process and she cries with every millimeter of bandage that is pulled off her face. I hold her hand. I fight my own tears and have to consciously control how I respond to this whole process – at which my conscious screams: it can be done better, differently, less painfully, maybe tomorrow. Maybe not. I bite my tongue until it bleeds. The graft has taken 80 per cent. For the first time I see her eyes open – they are big, brown, and moist. She is beautiful – even with her shaved head and blood streaming down her left check and dead skin hanging off the other.

The reverse culture shock I experienced upon returning to Canada in late August was indeed quite stunning. The world that was familiar to me was suddenly drastically unfamiliar and I became more aware of the various layers of complexities within which we live in a new and distinct light. I took my time immersing back into the life and culture that exists here and was surprised at how long it takes to actually feel like you are grounded in what is suppose to be “home.”

Since my return to Toronto, work and full-time studies (again!), I have spoken with a number of clinical colleges at St. John’s Rehab Hospital and, more specifically, with fellow Massage Therapists about my experience in Cambodia. Through these various dialogues, presentations and conversations, I am recognizing the potential of Massage Therapy and the role it can play in the rehabilitation process in various settings and various scales.

However, in order to take on such challenges and have the capacity to do work that involves an international arm, the discipline of Massage Therapy needs to continue the professionalization process which involves continued development of educational programs, building and nurturing the development of clinical and critical problem solving skills and lastly and very importantly research activity.

As the journey of a mission in an international setting unfolds, I began to realize that travelling across real and imaginary borders, religions and cultures, it is not enough to simply cut out a piece of knowledge or technical skill and transplant it to another piece of the world. Respect and consideration of these various surroundings, which have very real and very human features, is essential. This way, the transfer of knowledge becomes an exchange and has the chance of becoming a pertinent and permanent element of a particular environment – such as health care practice or services.

Anna’s complete blog can be accessed at: www.annatopia-in-cambodia.blogspot.com


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