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OVERSEAS SPECIALIST SURGICAL ASSOCIATION OF AUSTRALIA
TEAM VISIT – CANCAR, FLORES
APRIL 29 – MAY 6, 2006
TEAM LEADER’S REPORT
DR MARK MOOREMB, ChB, FRACS PLASTIC AND CRANIOFACIAL SURGEON
Implementation of Dr John Hargrave’s mission in East Timor and Eastern Indonesia; providing a specialist surgical service to the disadvantaged where the service is not available or affordable
AIMS AND GOALS
1. To provide a regular, coherent reconstructive surgical rehabilitation service to patients with physical deformity, congenital and acquired in the region of Nusa Tenggara Timur (NTT).
2. At the request of staff at St Damian, and as a precursor to the anticipated ANTARA project to produce a visiting general surgical service to St Damian/St Rafael Hospitals.
3. To work clinically with, teach and train local counterpart health workers, doctors, nurses and community-based health workers in the management, treatment aftercare and follow up of patients with physical disability requiring reconstructive surgery, as well as general surgical complaints.
4. Through the inclusion and active involvement of accredited Indonesian General Surgical trainees and Plastic Surgeons with our team to contribute to surgical teaching and further develop the relationship between Australian and Indonesian specialist surgeons.
INTRODUCTION
The long standing programme of orthopaedic and reconstructive surgery and rehabilitation at St Damian Hospital, Cancar, Flores, NTT dates back to the work of Dr John Hargrave, a leprosy and burn surgeon from Darwin. His commitment to this institution, its staff and patients from the early 1990’s provides the solid base upon which latter specialist surgical teams have expanded the spectrum of work to include a much broader array of physical disabilities and deformities assessed and treated at St Damian Hospital.
With this visit we include for the first time a Specialist General Surgeon, this being an initiative of RACS prior to the possible start of the broader ANTARA project in NTT. Additionally, the absence of a resident general surgeon in nearby Ruteng over the last 1 – 2 years has resulted in increasing numbers of general surgical cases being presented for assessment and treatment by the plastic surgical teams on recent visits. At the request of Sr. Franseline and her staff consideration was given to including a general surgeon on this visit.
The most recent visit, in October 2005 saw for the first time the introduction of an Indonesian surgical trainee as an essential part of the team, allowing expansion of the teaching role from just the education of local staff. The success of this initial project in anticipation of the wider specialist surgical project in NTT, saw on this visit both a General Surgical Trainee from Solo and a recently qualified Consultant Plastic Surgeon from Jakarta actively participate as members of the team, both in a service role and also in a teaching role with their Australian counterparts. Dr Harianto, our long term local counterpart and leprosy surgeon to the region as always accompanied our team and assisted in the coordination of the team’s activities.
This continued expansion and evolution of the specialist surgical teams visiting Cancar confirms its role as a valuable forum for not only the provision of top quality surgical care, but also and excellent environment for teaching and knowledge transfer between the visiting Australian surgical teams and their counterpart Indonesian surgical colleagues. TEAM MEMBERS Plastic & Reconstructive Team Dr Mark Moore Plastic Surgeon / Team Leader Dr Irena Sakura Rini Plastic Surgeon – Jakarta Dr Robert Linacre General Surgeon Dr Sujoko Purnomo General Surgeon – Jogjakarta Dr Hendrikus Harianto Leprosy Surgeon – R.S. Sitanala Dr Brian Spain Anaesthetist Dr Steve Kinnear Anaesthetist Mr Aaron Lienonen Recovery nurse Sr. Penny Craig Theatre nurse Ms Ruth Boveington Coordinator
Counterpart staff, St Damian/St Rafael HospitalsSr. Reginaldis Kepala Ruang OK Ibu Viktoria Kepala Perawat OK Ibu Ernawati Perawat OK Ibu Sabina Perawat Anaesthesia Ibu Santi Perawat Ok Pak Kanisius Perawat OK
LOCATION St Damian and St Rafael Hospitals, Cancar, Ruteng, Kabupatan Manggarai, Flores, Nusa Tenggara Timur.
The local organisation for the visit and notification of patients was as always supervised and overseen by Sr. Franseline SSpS. She was also responsible for the delivery and organisation of the appropriate post operative nursing care, in concert with her colleagues in St Rafael Hospital.
A letter of invitation for the team was obtained from the Bupati of Ruteng, this again being coordinated by Sr. Franseline SSpS.
With changes to the medical registration requirements for Indonesia commencing in October 2005, appropriate exemptions for the team were obtained. The active role of Professor Ahmad Djojosugito, John Maxwell in Kupang, Triady S. Diredja and the AusAID staff in Jakarta in obtaining the appropriate exemptions and reporting documents from the Indonesian Medical Council and Indonesian Ministry of Health was essential in allowing the visit to proceed. OVERVIEW As the team has come to expect with visits to St Damian/St Rafael in Cancar, the progress and change is rapid. Since the last visit, some 6 months ago, as noted above, significant changes to the requirement for medical registration of visiting teams have come into effect in Indonesia. Parallelling this, the proposed ANTARA specialist surgical project has almost reached fruition and out team continues to expand its role as both a clinical surgical service and a conduit for surgical teaching in Eastern Indonesia. The last 2 years has seen a significant expansion of both the range of surgery undertaken and also the evolution in the level of surgical teaching and involvement with our counterpart Indonesian medical and surgical colleagues.
The visiting Australian surgical team on this occasion included Dr Robert Linacre, Consultant General Surgeon from Hobart in Tasmania to assist in the provision of a general surgical service to St Damian Hospital. He was accompanied by Dr Sujoko Purnomo, a final year general surgical trainee from Jogjakarta who’s addition tot he team was coordinated with the assistance of Professor Ahmad Djojosugito.
Following the success of having a Senior Plastic Surgical Trainee, Dr Kristaninta Bangun with the team on the previous visit, the team on this occasion was accompanied by Dr Irena Sakura Rini, a Consultant Plastic Surgeon from the Rumah Sakit Kanker Dharmais, Jakarta. The assistance of PERAPI, the Indonesian Society of Plastic Surgeons in facilitating the addition of Dr Irena to our team is similarly appreciated.
Following the arrival of the Australian members of the team in Bali, we were joined by our Indonesian colleagues at Denpasar airport. Travel from Denpasar to Labuanbajo occurred on this occasion via GT Air. As Merpati Airlines no longer fly daily to Labuanbajo the sole regular means of transport to this stop off point for Flores remains with GT Air. The support of the airline in transporting the team at a time when flights were heavily booked was much appreciated. The team having arrived in Labuanbajo early on Saturday afternoon was subsequently transported to Cancar in the new St Rafael bus. Arrival late afternoon allowed for a short patient consultation session with those patients who had arrived early.
Consultations commenced early on Sunday for both the Plastic and General Surgical teams with by day’s end between 110 and 120 patients having been assessed. Surgical lists were then constructed with others waitlisted for future surgical visits.
The anaesthetists also on this day examined the operating theatre complex and checked the anaesthetic facilities. Since the last visit 6 months ago, piped oxygen and nitrous oxide have become available.
The nursing staff accompanying the team, neither of whom had been to Cancar before, acquainted themselves with the theatre complex.
In the succeeding days further patients arrived, some of which were able to be added to theatre lists, but because of insufficient time were by necessity waitlisted for future visits. By week’s end just under 170 patients had been assessed by the team.
GENERAL SURGERY The general surgical operative week actually commenced with Dr Linacre travelling to Ruteng in the company of Dr Yosef, the resident surgeon 6 months into his 1 year term visiting from Surabaya. Dr Linacre assisted the local surgeon with an emergency laparotomy prior to his return to Cancar for the upcoming weeks work.
At Cancar the surgical days were long, frequently running from 8 in the morning until 6 or 7 at night. The most common general surgical procedures were thyroidectomies, followed by procedures best described as ‘other head and neck’. There were 3 cases of neglected or late presentation of infant hernias and a wide range of other essentially superficial procedures.
Two laparotomies were performed on semi-emergency cases presenting during the course of the week. The first was a wide radical excision of a recurrent desmoid tumour with anterior abdominal wall reconstruction requiring both mesh and skin flaps. The other case involved removal of a massive bladder stone. Two other emergency cases taken included removal of a foreign body from the oesophagus and reduction of a dislocated shoulder. All cases were assessed as being fit for discharge by the time of the end of the visit, other than the 2 laparotomies which were well on the way to recovery. One minor complication occurred in which one of the infant hernias required evacuation of a small scrotal haematoma.
The presence of an advanced surgical trainee from Jogjakarta proved to be a great asset on this the first general surgical endeavour by visiting teams to Cancar. He provided excellent clinical support, a high level of surgical assisting skills whilst also having a role in translation and assisting in expressing the post operative instructions to the local nursing staff in a fashion that was most easily understood by them. His cheerful, helpful and uncomplaining personality proved to be a great asset to the Australian general surgeon on his first visit to Cancar. He was also able to ‘teach the teacher’ in the case of the bladder stone. It is recommended that such surgical advanced trainees continue to have an active role with such visiting teams.
PLASTIC SURGERY The provision of a plastic surgical service to St Damian Hospital has a much more lengthy history. In accord with this ongoing regular plastic surgical commitment to this institution, the team once again assessed a large number of patients. These cases were largely appropriate for assessment by the plastic surgical service.
Yet again large numbers of cleft lip and palate patients were assessed and treated. With the cleft patients operated on on this visit, the total number of cleft procedures undertaken in Cancar since 2002 is now approximately 220 cases. These patients came from as far a field as Kupang and Atambua in West Timor, from Bajawa, Ende and Maumere in Flores and also from Sumbawa.
A number of old burn contracture patients previously managed by the team presented for further assessment and treatment. In addition a significant number of new and extensive burn contractures presented for surgical correction. Among the old burn contracture patients the teenage girl treated on the last visit had undergone an extensive course of splinting and physiotherapy after surgical release and skin grafting. With this high quality of physiotherapy assistance she had extended considerably the range of movement that had been achieved at surgery. This is an outstanding result, testament to the high quality of physiotherapy and splinting services available in Cancar.
Among the other cases were a number of head and neck tumours, some of which had been seen previously and others which were new presentations. The attempted removal of one such vascular lesion in the left face resulted in only a partial excision, this surgery having to be terminated because of excessive vascularity of the lesion. A further vascular lesion involving the nose and medial edge of the maxilla was completely excised with a dramatic aesthetic improvement.
On the teaching front a large number of cleft cases assessed and surgically treated provided an excellent forum to demonstrate the full range of surgical repairs of cleft lip and cleft palate. Dr Irena was able to be actively involved in this and performed a number of cleft lip and cleft palate repairs. Demonstration of a more aggressive exposure of the midfacial skeleton added considerably to her past experience of cleft lip repair.
The plastic surgical cases were all stable and largely able to be discharged from the acute care setting prior to the team’s departure. A number of the burn contracture cases will require ongoing dressings and provision of splinting and physiotherapy. This will again be overseen by Ferdi Jelalu and his physiotherapy staff on site at Cancar. A number of these patients will require further surgery on the next visit and several of these will remain at Cancar until that time.
Dr Harianto once again joined the team, albeit several days late due to the unavailability of seats on the planes from Denpasar. He did indeed give up his seat from Denpasar to allow Dr Sujoko to join the team. Dr Harianto’s commitment is perhaps demonstrated by his 50 hour trip on ferries and buses to arrive and join the team. Almost immediately upon his arrival he commenced operating, undertaking a large number of the smaller local anaesthetic excisions, thus freeing up the team to undertake the more complex cases. His involvement and coordination of our visits ensures that he remains an integral part of our team.
The post operative management of the cases again occurred both within the St Damian and St Rafael Hospital complexes. With recent changes in Indonesia in terms of the provision of health care for the poorer patients, there were more patients able to be managed in the St Rafael complex with there being provided letters of support such that the local government undertakes to oversee the hospital costs. This was successful in somewhat reducing the post operative workload in the St Damian area.
Assessment of the overall Cancar complex shows ongoing changes with every visit. On this occasion further building is being undertaken with the provision of a small preschool and schooling area within the complex itself. In addition, considerable improvement in mobile phone coverage was noted with widespread coverage available due to the opening of a new transmitter during the middle of the week the team was there. This assists with communication between the team and the outside world.
At weeks’ end the team returned to Labuanbajo having been notified that the return plane from Labuanbajo to Denpasar would be leaving one and a half hours early. An uneventful flight home thereafter ensued. Dr Irena returned to Jakarta one day earlier than the rest of the team, but Dr Sujoko returned with the team to Bali prior to his onward transfer to Jogjakarta. SUMMARY OF VISIT Strengths
Weaknesses
SUMMARY OF CLINICAL ACTIVITIES APRIL 29 – MAY 6, 2006.
TOTAL PATIENT CONSULTATIONS 168 Plastic Surgical 110 General Surgical 58
TOTAL SURGICAL PROCEDURES 105Cleft lip/palate 23 Burn 10 Hernia 03 Thyroid (Goitre/Thyroglossal) 09 Others (inc. LA biopsy, cancer, tumours etc) 60
SUMMARY OF TEAM ACTIVITIES
April 28, 2006. Team members assemble in Denpasar April 29, 2006. Team departs Denpasar for Labuanbajo with onward road travel to Cancar where met by SSpS nuns and staff. Team joined by Dr Irena and Dr Sujoko Outpatient consultation April 30, 2006. Outpatient consultations and preparation of operating theatre May 1, 2006. Operations / consultations / ward round May 2, 2006. Operations / consultations / ward round May 3, 2006. Operations / consultations / ward round May 4, 2006. Operations / consultations / ward round May 5, 2006. Operations / consultations / ward round Farewell dinner with SSpS sisters Dr Irena departs for Jakarta May 6, 2006 Team departs Cancar for Labuanbajo and onward flight to Denpasar Dr Sujoko departs for Jogjakarta May 7, 2006. Team departs Denpasar for Australia ACKNOWLEDGEMENTS
OSSAA CANCAR, FLORES, N.T.T. 2000 – 2006.
TOTAL CONSULTATIONS 1374TOTAL SURGERY 624
CLEFT SURGERY 215 BURN SURGERY 76 ORTHOPAEDIC 130 OTHERS 200
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