A year ago, I had the incredible opportunity of being able to take, transfer, and apply my skills in scar massage to a setting that is worlds apart from any reality I have encountered or experienced before. 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, Ontario, and traveled to Cambodia where I worked at Children’s Surgical Center (CSC) providing and teaching scar massage that could be applied in the postoperative treatment of acid burn victims and other burn survivors.

It was an experience that impacted me in various ways, personally and professionally. On a professional level, it made me realize the very real therapeutic benefits of scar massage intervention and the incredible contribution people can make when they get their hands in there — literally and figuratively.

During my time in Cambodia, I kept a travel journal in the form of a blog. I wasn’t sure what I would be writing about, but the process of writing in and of itself makes me stop long enough to at least
consider, digest, and contemplate what is happening around me. The following are a few excerpts directly related to my experience as a clinician, a healthcare professional, a massage therapist, and a human being.

Monday, April 18, 2005 — Why

The last time I returned from a trip, I made a decision: From now on, travel will not only focus on fun and relaxation, but will also involve contributing in a way other than spending American dollars.
So, this trip to Cambodia is focused on a project — working at a burn hospital and teaching scar massage to one or two individuals who will be able to provide it as part of the postoperative therapy to burn victims. The work will also involve scar massage treatment which focuses on decreased stiffness and tightness of the scar tissue, improving the mobility (or pliability) of the scar tissue, and preventing restricted joint movement and contractures.

I leave May 11 and will be in the region for three months. As I travel from one world to the next, embark on a solo trip (a first in my life), and contemplate how to actually do this (teach, live, and treat in a place like Cambodia), I’ve decided to keep a log. I would like to be able to share this experience — although I’m not sure exactly what I will be sharing. However, the process of writing makes me stop long enough to process what I’m involved with directly and indirectly — so it goes beyond being a passive observer to realizing that there is impact from being present.

Saturday, May 14, 2005 — Pictures Come to Life

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 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 I say thank you, voice becoming a little softer. I feel that every time I step out, I sink a little deeper into my new surroundings.

I went to CSC with the physical therapist, Mr. Ath, for about 15 minutes to get a sense of it (Ath is away for four weeks on a mission with the army, and I am being handed the keys to the physical therapy room). While he is away, there will be no physiotherapy. 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 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 many patients 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 there are two burn victims — a man and a woman. One has 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 nervousness 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 painkillers. They were so quiet, suffering in silence. I imagine after a while they just don’t have the energy to express the suffering they feel.

I feel like I have taken the final steps from being an idealistic student constantly up in arms with the world and the order of things to becoming someone who accepts the fact that’s the way it is and human nature is complex in its simplicity — that smaller changes over time are more meaningful than grand dreams with no action to follow. I am becoming a realist. My romanticism is reserved for more private moments.

Wednesday, May 18, 2005 — Observing, Absorbing

The brown iodine mixture that is put on wounds mixes with the lotion I use to massage the scars. It makes a funny yellow color 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 bone because there is much less fat. The scars are much thicker and the contractures severe. The deformities are 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 patients’ eyes.
There is a very specific smell in the air. A smell that is common here because it is a 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 I know I’ll get 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 patients’ 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 is part of the shock the whole country is still in after the atrocities the population here suffered — in the face of something tragic, people simply stare. Their gazes follow me as I travel between 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.

Saturday, June 4, 2005 — Full Circle

The operating room is cool and smells very sterile. It is a potent smell — a little like Vick’s Vapor Rub, 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 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 was 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 backward. On the ears and the left mandible, the wounds developed into massive keloid scars. This was the second surgery — a release surgery to release the scar and move the joints back into proper position.
Back to the operating room. I walked in toward the end of the hip release part of the surgery. The doctors were 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 no resistance or response. It seems much more malleable. The leg has no personality, 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 gauze to clean up and absorb 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 joints. How quickly and easily they go in. I wonder what type of resistance the tissue gives to the needles? What is it 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 the recovery room, the boy starts to wake up. He throws up. The next morning there is significant bleeding in the left hip region. In the dressing room, the nurse starts to take off the bandages while the boy screams in pain. I realized he probably was not given any painkillers. The surgeon comes and it’s decided the grafting will be touched up under anesthesia because it is too painful otherwise. The parents are quiet, somber, helpless.
In the afternoon, the boy starts to wake up again. He’s holding down fluids. He smiles as I show him a picture I took the other day of him kicking a ball.

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 color, 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.

Tuesday, June 14, 2005 — On the Edge of Violence

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 crossroad. I hit points of saturation daily, at which point I need to mentally switch gears or walk away for a breath of something else, 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 it’s a criminal act, it is uncommon for these burn victims to take their assailants to court. Some reasons why (as explained to me by various individuals) are: the victim is poor, uneducated, and unaware of their rights; it costs too much money for lawyers; and the victims are afraid the assailant will do them more harm. A couple of cases were recalled where the lawyer ended keeping all of the money awarded to the victim. The explanation was simple — the system is corrupt. This is by no means the beginning or the end of reasons.

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 the stories of these individuals ... stories that give a human face to impersonal statistics and numbers.

Acid attacks seem to be acts based on jealousy or revenge, usual in context of personal relationships, a way of dealing with family or marital problems. Often women are the victims, but, there are also a number of men. Specific situations that have been related are: The husband has a second wife (a mistress) and the first wife is jealous or not happy with this situation and “deals” with the problem of infidelity by pouring acid on the second wife. Sometimes the husbands are the victims of such emotional reactions. Sometimes the attack is based on suspicion — the wife thinks her husband is having an affair. Sometimes it is an act of anger — the man who is denied by a woman he fancies strikes back by pouring acid on her. Or a husband who is angry at his wife because she wants a divorce pours acid on her. Sometimes the attacks are more random — a case of mistaken identity or it is accidental (it was really meant to strike the person next to you).

I often travel between two worlds — the one I can relate to and the one with realities I am just beginning to grasp. I can’t imagine pouring acid on someone as a way of dealing with marital problems or problems in general. At what 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? From where is this type of brutality born? 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 that burned its way through flesh and muscle ... it is very real. I feel it 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.

The response of this society to acid burn victims is to look away. People are scared of the scars, disgusted with the disfigured appearance. A common trend within this group of individuals is that none of them are able to find work. Their abilities are secondary. The primary factor is that they are disfigured and therefore people do not want to work with them or hire them, afraid of the impact it would have on their business. I am curious to explore this prejudice, this reaction. In a conversation with a foreigner, they pointed out that part of the reason why disabled individuals have a such a difficult time is that people believe that bad things have happened to them because of karma — they were bad in a past life and now this is what happens. I am exploring this more.

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. They will end up living out their days making money off their scars and deformities as beggars, enough money for one meal a day — 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.

Saturday, July 9, 2005 — A Tender Moment

She is the only acid burn patient currently at CSC. She arrived one week ago. I first saw her during rounds sitting in the main ward, her face charred, hardened pus on her chin. Her eyes were shut from the scars. There are some splatters from 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 look puffy, as if he’s been crying) and his tattoos — the ones that men get here to keep bad spirits away. I haven’t seen this many on one body before.

As I’m treating the patient, he watches. And then he picks up his wife’s burned hand and begins to massage it, mimicking what I did. He’s shaking. I feel a bit uncomfortable watching this tender moment. 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. 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 percent. For the first time I see her eyes open — they are big, brown, and moist. She is beautiful — even with her shaved head, blood streaming down her left cheek, and dead skin.

July 14, 2005 — Sand Slipping Through My Fingers

I am leaving Cambodia. I am leaving pieces behind for pick up when I return. I realize this on the plane and smile.

I leave Cambodia having developed a new relationship with time: Its amplitudes are different, its velocity varies, but defines itself by infinity. Sometimes it slips through my fingers like sand. Sometimes it feels like space full of invisible pulses.

I leave Cambodia with the smell of jasmine surrounding me. I am drawn to it, and I have smelled it long enough that it has become a part of me — a smell that I always recognize and find myself lingering and drifting to inhale. That is the beauty and magic of flowers.

Postscript

The reverse culture shock I experienced upon my return to Canada in late August was indeed stunning. The world that was familiar to me was suddenly drastically unfamiliar, and I became more aware of its various layers of complexities within which we live in a new and distinct light. I took my time immersing myself 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 supposed to be home.

Since my return to Toronto, work, and full-time studies, 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 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 begin to realize that travelling across real and imaginary borders of countries, 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, are essential. In this way, the transfer of knowledge (and skills) becomes an exchange and has the chance of becoming a pertinent and permanent element of a particular environment.

Anna Kania is a Canadian massage therapist who spent two months in Phnom Penh, Cambodia, providing scar massage treatment. Her complete blog is available at www.annatopia-in-cambodia.blogspot.com.

To Donate

Donations to the Children’s Surgical Center and the Scar Massage Project can be made online http://individual.utoronto.ca/organek/summit

Or mail donations to Sunnybrook & Women’s Foundation
Cambodia Children’s Summit Ride
Attn: Dr. Massey Beveridge
H-Wing Room H-332
2075 Bayview Ave.
Toronto, Ontario M4N 3M5