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TEAM VISIT – TIMOR LESTE
APRIL 21 – 29, 2006
TEAM LEADER’S
REPORT
DR. MARK MOORE MB,ChB, FRACS PLASTIC AND CRANIOFACIAL SURGEON
Funded by AusAID through the Royal Australasian College of Surgeons (RACS)
Implementation of Dr John Hargrave’s mission in Timor Leste and Eastern Indonesia: providing a specialist surgical service to the disadvantaged where the service is not available or affordable
Aims and Goals
The objectives of this surgical mission remain as previously identified:
1. The provision of a regular, dedicated Plastic and Reconstructive Surgical service to the people of Timor Leste, by a team whose personnel have a consistent commitment to this region.
2. Active participation in the teaching and training of our counterpart East Timorese surgical, anaesthetic and nursing staff at the hospitals at Dili and Baucau.
1 The provision of a regular, dedicated Plastic and Reconstructive Surgical service involving consistent team personnel to the people of Timor Leste 3. Commitment to a continued expansion and evolution of a wide community-based referral network for all those patients with physical disability and deformity such that they can access both surgical treatment and appropriate ongoing post surgical therapy and rehabilitation.
IntroductionThe April 2006 OSSAA Plastic and Reconstructive Surgical mission to Timor Leste is the 10th such visit, performed under the auspices of the AusAID sponsored RACS East Timor Specialist Surgical Specialties Project. This represents the last undertaken by this team under the existing agreement, although it is anticipated that this service will continue with some minor modifications after July 2006. This team, with this visit has now completed 19 clinical and surgical visits to Timor Leste since March 2000. Reflecting the consistency of personnel, several team members have individually undertaken 19 such visits whilst a number of others in the team have been active participants on more than 10 occasions. Two members of this team on this visit were new to Timor Leste but have undertaken similar such surgical missions elsewhere in Indonesia.
With the well established successful pattern of clinical consultations and surgical treatment, the team spreads its workload between both Dili and Baucau Hospitals. Advanced communication with various East Timorese counterparts once again ensured that consultation clinics were also performed at the Bairo Pite Clinic, Dili; the Maryknoll Sisters Clinic in Aileu and at the PAS Clinic at Becora. As a follow up from the team’s previous visit when a trip occurred to the island of Atauro, communication with this more remote region ensured that a number of patients from this area presented for treatment on this visit.
Recognising the commitment of the team to Timor Leste, the team was once again hosted by the Australian Ambassador, Margaret Twomey, to recognise the team’s work in this region.
This visit was held in Timor Leste at a time of arising political and social tensions with demonstrations by dissident soldiers held in Dili for 5 days during the team’s visit. This produced some heightened tension during the week and a requirement for the team to assist in the treatment of those injured in the protests on the final day of the visit. It is to be hoped that these present difficulties in East Timor stabilise to allow ongoing management of those with physical disability and deformity. Team PersonnelPersonnel included in the team were: Dr. Mark Moore - Plastic Surgeon / Team Leader Dr Antonio (Tony) Fernandes - Plastic Surgeon Dr Michael Klaasen - Plastic Surgeon Dr David McLeod - Anaesthetist Dr Peter Malcolm - Anaesthetist Sr. Elizabeth Mazzei - Operating theatre nursing sister Sr. Penny Craig - Operating theatre nursing sister Ms. Ruth Boveington - Coordinator / interpreter
Locations and counterpartsBairo Pite Clinic (Dili) Dr Dan Murphy – General Practitioner Dr Fatima – General Practitioner Aileu Clinic Mr Rogerio de Conceicao – Nurse Clinic Manager
Baucau Regional Hospital Dr. Philip Mwaura – Resident General Surgeon Sr. Alcino Timotai Gaia – Nurse in Charge, operating theatre Sr Antonio X Bento Correia – Anaesthetic Nurse Sr Anselmo – Anaesthetic Nurse
Dili National Hospital (Hospital National Guido Valadares) Dr Eric Vreede – RACS anaesthetist Dr David Hamilton – Resident RACS General Surgeon Dr Nilton – Surgical Trainee Dr Flavio – Anaesthetic Trainee Sr Francisco – Theatre Nurse Sr Moises (Andre) – Theatre Nurse Sr Antonio – Anaesthetic Nurse Sr Nicolo – Anaesthetic Nurse Sr Jose – Anaesthetic Nurse Sr Carlos – Anaesthetic Nurse Mr John – Nurse in Charge, Operating Theatre
PAS Clinic (Dili) Sr. Maria Dias – Nurse Clinic Manager
Resident RACS Coordinator Mr Sarmento Correia
Following the last visit a concerted effort was made to communicate early with the RACS visit co-ordintor Mr Sarmento Correia to attempt to ensure that appropriate communications were made to the outlying regions to give patients adequate notice of the team’s impending visit. This was perhaps assisted by a recent visit to East Timor by Dr Tim Keenan, Orthopaedic Surgeon, who in the process of visiting most of the districts of Timor Leste was able to reinforce the message that the Plastic Surgical Team was coming. Once again the distribution of patients was somewhat uneven with one or two areas being very well represented whilst others such as Suai, Oecussi and Los Palos remaining largely untouched. The timing of this visit, towards the end of the wet season may also have led to some difficulties in patients coming from more remote mountainous areas where there was considerable flooding. Travel for both patients and the teams at this time was a little more challenging than usual.
A clinic was once again held at the Bairo Pite Clinic where Dr Fatima, a young East Timorese doctor recently returned from training in Indonesia, discussed and presented cases to our team members.
Following this a clinic was once again held in Aileu, identifying a small number of cases which needed to come to Dili for treatment whilst saving others from the need to come down to Dili for assessment.
Clinics were once again held both in Dili and Baucau hospitals with the numbers and triaging of cases being quite satisfactory. The surgical and anaesthetic members of our team changed their location on this occasion with Dr Moore returning to Dili after a couple of years absence and Dr Fernandes undertaking the clinic in Baucau for the first time. OVERVIEW The well established pattern of assessment and surgical intervention continued on this visit. Indeed the new surgeon to the team quickly noticed and commented upon the easy manner in which the clinics were organised and patients assessed and treated. This I think is a positive reflection on the consistency of team personnel involved in this region.
Clinics were held once more at the major hospitals in Dili and Baucau. These undertaken on the Saturday of the beginning of the visit allowed for assessment and construction of the surgical lists for the following week. Smaller outreach consultation clinics were held at the Bairo Pite and PAS Clinics in Dili, as well as in Aileu.
With the completion of this visit the team has now assessed just under 1900 patients and have performed approximately 650 surgical procedures since June 2000.
All surgeons arrived on the Friday of the week prior to the operating surgical week. This allowed all surgeons to be involved in the outreach clinics in Dili and Aileu. With the arrival of the remaining teams on the Saturday, the team split to continue with its more major clinics in Dili and Baucau. Early in the visit members of the team were warned of potential social unrest associated with disaffected members of the army. During the operating week a significant area of Dili was cordoned off, although this caused few problems for the team’s activities.
The appropriateness of clinical referrals again remained high. An excellent turn out in Dili was evident on this occasion, perhaps reflecting the emphasis made with the RACS Coordinator to get the message out to remote regions. As noted above, there do remain areas from where patients do not appear to present in the numbers one would expect. An attempt was made prior to this visit to extend the service to Oecussi. Travel difficulties meant that on this occasion it was not possible, although ongoing negotiation will be held to establish whether such a visit would be possible during the next planned mission.
At the Dili Hospital clinic previously waitlisted cleft lip and palate patients were placed on the surgical list and on this visit a good number of new cleft patients were once again seen. This was again a mixture of infants newly presenting with cleft deformity, but there remained again older children and indeed adults with unrepaired clefts. Included in the latter was a 34 year old lady with an unrepaired incomplete cleft lip who had six children.
The consulting clinic in Baucau again saw a smaller number of patients being assessed. From within this group some 16 cases were selected for surgery which occurred over the three and a half days of operating in Baucau. As has always been the case, Dr Phillip, the Resident General Surgeon provided excellent support for the team, particularly as this was their first occasion working in Baucau. There were no other issues of note for the team in Baucau prior to their returning to Dili on Thursday afternoon.
The surgical week in Dili commenced with the hospital being relatively full, there having been a bus accident the previous day, resulting in injuries to 30 or more nuns. Surgery commenced on Monday, but shortly into the day issues were raised regarding the availability of beds and nurses. With the intervention of Sr. Maria Dias, who was able to get approval from the Director for an expanded new ward area. When the issue regarding nursing coverage for this was raised, she similarly intervened to ensure the nursing availability for this area. The building which appeared newly painted functioned as a large open plan ward and provided an excellent environment for our plastic surgical patients. This was in stark contrast with some of the wards which given their intensive use, do not appear to be the cleanest. In addition, the placement of our cleft patients in with a whole range of other general and orthopaedic surgical problems is far from conducive for after care. When they were placed in this large open ward with patients with similar problems, they mobilised more rapidly postoperatively. The children were able to be carried by their parents outside and generally the post operative course was far less complicated. This contrasted with several patients treated in the conventional wards who became febrile post surgically and whose nursing aftercare was less than ideal. Given our team’s past experience, with post operative complications, I would recommend that our future visits utilise this facility. Indeed, the issue should be raised of it becoming a paediatric surgical ward and/or an area to be utilised by visiting specialist surgical teams. As a general rule, our patients are well and can be mobilised and got out of the wards much faster when treated in this fashion, rather than when placed in wards with patients who have long standing surgical complaints.
In both centres a large number of cleft patients were once again treated and indeed, by pushing the service on this occasion we were able to perform more cleft procedures than has been possible over recent trips. A number of old and new burn contracture patients also presented for assessment and treatment. These remain a significant workload and with improving post operative physiotherapy and splinting services through organisations such as ASSERT it should be possible to further expand this service over time.
A number of the smaller cases, including scar revisions and excision of local lesions about the face and trunk, were able to be treated with the assistance of Dr David Hamilton, the Resident RACS General Surgeon. His assistance was of great help to the team and allowed us to concentrate on the more complicated procedures.
On the last day of the team’s surgical programme in Dili unrest and violence in the city centre escalated resulting in the team’s list being foreshortened. Several members of the team provided assistance to Dr Hamilton with patient management prior to the final team members departure from Dili. Organisational and administrative issues requiring further comment include:
Travel to East Timor on this occasion presented no specific difficulties. The support network from the International Projects Office ensured that an excess baggage allowance had been approved with the airlines and a similar such communication had been passed to Immigration Office in Dili so there were no difficulties passing through Immigration without the requirement for the visa fee to be paid.
The departures from East Timor were complicated for a portion of the team due to the unforeseen social unrest. This was an issue beyond anyone’s control.
Accommodation for the team had been organise by Mr Sarmento Correia in Dili at the Hotel Turismo and in Baucau at the Pousada de Baucau. There were again no issues at all in relation to the accommodation , although the room rates for the hotel in Baucau have once again increased. It would be useful if Mr Sarmento could pass to the team leader in advance the likely cost for rooms at the institutions as this helps in planning the financial side of the trip.
Travel support for the team was once again provided by Thrifty Car Rentals in Darwin courtesy of Mr Brian Measy. On this occasion vehicles were provided to both the Dili and Baucau team, providing everyone with easy movement between the accommodation and the hospital, allowing for the return to the hospital at any hour.
a) RACS Coordinator The team had been assured that notice of the team visits is forwarded to all centres. It should be noted from the report of Mr Tim Keenan, who travelled around East Timor some 2 – 3 weeks prior to our team’s arrival to review the situation regarding orthopaedic surgery, that a number of regions had no knowledge of our plastic surgical team’s arrival on the dates that were planned well in advance. It would thus seem that there is some failure in communication and that better notification of impending specialist surgical team visits can occur. At this stage I am not aware of the exact process whereby notice of the team’s arrival is passed to the communities. Notice is I believe placed on local television and radio, but there are significant areas of East Timor where this information will not get through. Direct communication with the Ministry of Health and notices to all Heads of the District Health Services should be standard practice. What then happens within specific districts may be out of the control of the RACS Coordinator but the team’s do need to be assured that the message is in fact being sent to all districts.
On this occasion the RACS Coordinator accompanied the team to Baucau and was present for a period during the outpatient clinic on the Saturday, but was not seen thereafter. It would appear that he returned to Dili by sometime on Wednesday afternoon but was again not seen by members of the visiting team in either a formal or informal fashion thereafter. His assistance with translation would have been appreciated in Baucau.
b) Outpatient Clinics The outpatient clinics at both hospitals again proceeded in an extremely efficient fashion. The staff of the outpatients, particularly at Dili Hospital should be commended for the fashion in which they run the clinic. On this occasion it commenced mid morning on Saturday and went until at least mid afternoon with some 50 or more patients being seen during this period.
c) Operating Theatre In Baucau the operating theatre staff again functioned in an efficient manner. Two of the nurse anaesthetist trainees who are from Baucau returned there for the week to further their experience with the anaesthetist on our team. In Dili this was a similar feature with some four nurse anaesthetist trainees working with the team’s anaesthetist as well as one of the local doctors who has an interest in training in anaesthesia.
At Dili Hospital it would appear that two of the nursing staff were allocated to our team for the week and these staff, Mr Francisco and Mr Moises provided an excellent level of service and should be highly commended for their work with the team. None of the other nursing staff made any attempt to work with the team and really failed to utilise the opportunities both to educate themselves and to learn from the visiting teams.
The theft of a visiting surgeon’s mobile phone from the operating theatre on the second last day of operating rather diminished the level of trust between the team and local staff. The actions of one person however should not diminish the excellent work of the nurse anaesthetists and nursing assistants who worked with the team.
d) Surgical Ward Post Operative Management As noted above, significant issues occurred in relation to the surgical wards and post operative care. Children placed the first night in the women’s surgical ward did not receive the analgesic and anti-pyretic agent medication that was charted and despite a significant incident on a previous visit, the nurses in this environment appear not to have absorbed past lessons. Only with the opening of the new ward area and the placement of all our patients in this open ward, did the team have any confidence in post operative care. It should be noted that most of the cleft lip and palate patients are only transiently unwell and indeed come into hospital well to have a relatively straight forward procedure. They should by day one or two be back eating and drinking normally. They are thus different from the other longer stay and intrinsically unwell patients that languish in the wider general surgical wards. For that reason the use of this new ward area was a significant advance in the level of post operative management and aftercare. It would thus be a recommendation of the team that this facility be made available for subsequent visits.
e) Medical Staff In Baucau, as has always been the case, Dr Philip provided excellent support to the visiting team. Dr Joao Pedro, the local surgical trainee is away in Papua New Guinea at present and hence not available to assist on this occasion.
In Dili excellent support to the team was provided by Dr Flavio who was interested in a career in anaesthetics. From the surgical viewpoint, Dr Nilton made himself available on a couple of occasions to observe and assist in surgery. Dr David Hamilton, as noted previously, provided an excellent level of support for the team and actively interacted with the visiting team in a regular fashion. Dr Eric Vreede, the RACS Resident Team Leader, also provided excellent support and assistance in an administrative position to the team.
Visit AssessmentStrengths:
Weaknesses:
Clinical Summary – September 23 – 29, 2005
Total patient Consultation: 122 Dili (Mark Moore) 94 Baucau (Tony Fernandes) 28
Total Surgical procedures: 57
Dili 41 Baucau 16
Cleft lip 31 Cleft Palate 07 Burn contracture release 06 Others 07
Local anaesthetic procedures 06 Summary of Team Activities – April 21 – 29, 2006.
April 21, 2006. First team members depart Darwin to Dili. Consultation clinic in Bairo Pite Clinic, Dili and Maryknoll Sisters Clinic, Aileu. Remainder of team arrive in Darwin.
April 22, 2006. Remainder of team arrive in Dili Part of team departs Dili for Baucau – outpatient clinic at Baucau Hospital. Remainder of team for outpatient clinic in Dili
April 23, 2006. Surgical lists are compiled and delivered to respective s Hospitals. Dili team visit Sr Maria Dias at PAS Clinic
April 24, 2006. Surgical procedures at Dili Hospital Surgical procedures at Baucau Hospital
April 25, 2006. Surgical procedures at Dili Hospital Surgical procedures at Baucau Hospital
April 26, 2006. Surgical procedures at Dili Hospital Surgical procedures at Baucau Hospital
April 27, 2006. Surgical procedures at Dili Hospital Baucau team members return to Dili
April 28, 2006. Surgical procedures at Dili Hospital Part of team depart Dili for Bali.
April 29, 2006. Remainder of team depart Dili for Darwin
Acknowledgements: • Royal Australasian College of Surgeons – RACS / AusAID for their continued support of this team’s work in Timor Leste • The resident RACS , anaesthetic and surgical team in Timor Leste and the staff of both Government hospitals • The operating theatre staff at Dili Hospital • Sr. Maria Dias, PAS Clinic • Mr Rogerio Conceição, Aileu Clinic • Dr Dan Murphy and staff at Bairo Pite Clinic. • The Maryknoll Sisters, Aileu for their highly valued long term commitment to the people of Timor Leste and for their continued assistance with our work. • The various Australian public and private hospitals and surgical and pharmaceutical supply companies who so generously support this team’s work. A special note should be given to Johnson and Johnson representatives who provided specialist suture supplies for the team. • Mr Brian Measy and the staff of Thrifty Car Rentals, in particular Mr Sean McIlroy for their continuing assistance with transport for the team in Timor Leste. • For all those team members, new and old, and their families who continue to commit so fully to this work in Timor Leste.
Mark H. Moore, FRACS Plastic and Craniofacial Surgeon Team Leader - OSSAA
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