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OVERSEAS SPECIALIST
SURGICAL ASSOCIATION OF AUSTRALIA |
ROYAL
AUSTRALASIAN COLLEGE OF SURGEONS |
ANTARA – RACS NTT PROJECT
TEAM VISIT –
CANCAR & RUTENG, FLORES
OCTOBER 7 –
14, 2006
TEAM LEADER’S REPORT
DR
MARK MOORE
MB,
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.
The provision of a regular, coherent reconstructive surgical
rehabilitation service to those patients with physical deformity,
congenital and acquired in the region of Nusa Tenggara Timur (NTT),
Indonesia.
2. Maintain continuity of the long standing orthopaedic surgical service
to the St Damian/St Rafael Hospitals.
3. To undertake a preliminary visit to the Government based hospital
facility in Ruteng as part of the extended ANTARA project in the province
of Nusa Tenggara Timur.
INTRODUCTION:
The work of
the OSSAA based plastic and reconstructive and orthopaedic surgical teams
at the St Damian Hospital complex, Cancar, Flores is an extension from the
work commenced by Dr John Hargrave, leprosy and burn surgeon from Darwin.
He first commenced his programme his region in the early 1990s. The last
five years has seen a systematic and coordinated expansion of the surgical
assessment and operative workload for those patients presenting to St
Damian Hospital with a broad array of physical disabilities and
deformities.
Subsequent to
the last team visit to Cancar in May 2006, the expansion of surgical
services to NTT under the ANTARA project has commenced. Based upon the
work of our team in Cancar, together with the team visiting Kefamenanu in
West Timor, this AusAID sponsored project sought to broaden the range and
location of specialist surgical services being delivered by volunteer
Australian surgical teams across the province of NTT. In line with this
it was hoped that this present team would also visit the nearby town of
Ruteng and assess the possibility of a similar service being provided at
that location.
Where the
most recent visits have included Indonesian surgical trainees, it was not
possible on this occasion to add these personnel to our team. It would
appear that the reasoning for this on this occasion involved the visit
occurring in the period of Ramadan with resultant non-availability of a
large number of trainees, particularly from Java. In addition the formal
teaching and training component of the ANTARA project still awaits formal
ratification by the Government authorities in NTT. This was also seen as
a factor in the failure to attract trainees to this visit.
The team has
always included our local counterpart Dr Harianto, who again provided a
valuable role in both assessment of patients, as well as undertaking a
large number of local anaesthetic surgical procedures, which freed up the
visiting Australian surgeons for the more complex cases.
The
healthcare facility in its broadest expression at St Damian, Cancar
continues to flourish with a further outpatient consulting area being
added to the ward accommodation block recently completed in 2005. Further
building in the complex is ongoing with a small school for the disabled
children nearing completion. In recognition of the excellence of this
facility, large numbers of patients, together with family and also the
religious sisters who provide coordination for their management, continue
to arrive from Flores as well as from West Timor and Sumba.
TEAM MEMBERS
Dr Mark
Moore Plastic Surgeon / Team Leader
Dr Tim
Keenan Orthopaedic Surgeon
Dr Hendrikus
Harianto Leprosy Surgeon / RS Sitanala
Dr Phil
Blum Anaesthetist
Dr Jerome
Wisniewski Anaesthetist
Sr. Penny
Craig Theatre Nurse
Sr. Elizabeth
Mazzei Theatre Nurse
Ms Ruth
Boveington Coordinator / Interpreter
COUNTERPART STAFF, ST DAMIAN/ST RAFAEL HOSPITALS
Sr.
Reginaldis SSpS Operating Theatre – in charge
Sr. Angela
SSpS Theatre Nurse
Sr Kanis
Nabur Theatre Nurse
Sr. Viktoria
Sanggo Senior Theatre Nurse
Mrs Ernavati
Kabora Theatre Nurse
Mrs Sabina
Bavu Anaesthetic Nurse
Dr
Tommy Dentist
Sr.
Franseline SSpS Ward and Outpatients – in
charge
LOCATION
- St Damian
and St Rafael Hospitals, Cancar, Ruteng, Kabupatan Manggarai, Flores,
Nusa Tenggara Timur.
- Rumah
Sakit Umum Ruteng
As with all
previous visits the local organisation and notification of patients was
supervised and coordinated by Sr. Franseline SSpS. She also oversaw the
post operative nursing care of the team’s patients and coordinated the
aftercare upon the team’s departure in concert with her nursing and
physiotherapy colleagues in both St Damian and St Rafael Hospitals, and
also in Binongko.
The team also
undertook a brief visit to the general hospital in Ruteng. There Dr Tim
Keenan was able to meet a member of the hospital medical staff and to
assess a small number of patients collected as outpatients in this
institution.
The work
undertaken in this area was again at the invitation of the Bupati of
Ruteng with appropriate formal letters of invitation having been obtained
prior to the visit.
OVERVIEW
The OSSAA
surgical team to Cancar on this occasion was a composite plastic and
reconstructive and orthopaedic surgical team. The individual surgeons and
anaesthetists were all specialists who have visited Cancar on at least two
occasions previously.
This visit
was perhaps unfortunately undertaken during the period of Ramadan, this
possibly being one of the factors behind an inability of Indonesian
surgical trainees from Java to join the team on this occasion. Concerted
attempts were made by both Dr Keenan and Dr Moore to attempt to expedite
the addition of trainees to the team from both Jakarta and Jogjakarta.
The, as yet uncompleted, training agreement between the NTT Government,
RACS and the Indonesian Surgical Training System was also seen to be a
factor in trainees not accompanying the team.
Despite this,
the team was once again ably assisted by Dr Harianto, our long term local
counterpart leprosy and burn surgeon. In addition the team was joined by
Dr Tommy, recently appointed dentist in the Cancar region, who showed
great enthusiasm to learn, particularly in relation to the cleft lip and
palate surgery.
In light of
the commencement of the ANTARA specialist surgical project in the province
of NTT, it was anticipated in advance of the visit that the overall
numbers may be slightly reduced. However on an advanced warning from Sr.
Franseline to the team coordinator suggested otherwise and this was
confirmed upon the team’s arrival. A large number of patients had
assembled prior to the team’s commencement of consultations in Cancar with
patients presenting from the length and breadth of Flores and also a
considerable number of patients from West Timor. The latter were referred
from both Atambua and Kupang through the network of SSpS sisters in
Halilulik and also following Dr Harianto’s recent visit to West Timor with
the ANTARA teams.
The initial
consulting sessions commenced on the Saturday immediately after the team’s
arrival in Cancar. This 2 – 3 hour consulting period on the Saturday
evening was followed by a full day of consulting on the Sunday, commencing
at 8.00 a.m. By day’s end approximately 200 patients had been assessed,
including 150 by the plastic surgical team. The slightly lesser number of
orthopaedic patients being assessed allowed time for Dr Keenan,
accompanied by several other members of the team, to visit the public
hospital in Ruteng. There a small number of patients were assessed in the
Outpatient clinic, several of these being placed on the waiting list for
surgery in the future. A member of the medical staff at the hospital was
present to meet the team and accompany them to the outpatient clinic.
Full surgical
lists were constructed following completion of consulting. Due to the
late finish of consulting on Sunday it was not possible to fully prepare
the operating theatre suite in anticipation of surgery commencing on the
Monday. As all but one of the team had worked extensively in Cancar
before, this produced no difficulties. The theatre itself remains
unchanged from the previous visit 6 months ago. The theatre was once
again presented in an immaculate state and the newly added piped oxygen
and nitrous oxide was still available. The local anaesthetic machines
which contain Halothane vaporisers were once again utilised with the use
of alternative anaesthetic agent Isofluorane providing a very adequate
substitute.
PLASTIC SURGERY
The plastic
surgical service which has formed the backbone of the OSSAA surgical
service to Cancar was again presented with a large caseload. On this
visit the team saw more cleft lip and palate cases that have been seen on
any previous visit. This likely reflects the satisfaction with surgery
undertaken previously and the assessment of results in the community,
resulting in dissemination of knowledge of the availability of the service
in Cancar. With the extremely well developed networks of the sisters in
St Damian, patients were referred from as far a field as Atambua in West
Timor, as well as throughout the length of Flores. On this visit more
than 50 new cleft lip and palate cases were assessed.
During the
working week the team was able to undertake some 42 cleft lip and palate
repairs, this being at least 10 more than has been possible on any
previous visit. It now brings to approximately 260 cleft surgical
procedures which have been undertaken in Cancar since the beginning of
2002. A number of cases included children whose cleft lips have been
repaired on previous visits and now presented for the definitive repair of
their cleft palate. There were also a number of cases, who have had
previous surgery elsewhere by visiting Indonesian surgeons, who presented
either for revision of their cleft lip or completion of their cleft palate
repair.
The post
operative management of the cleft cases again proved uncomplicated. The
post operative ward staff once again proved to be highly professional and
enthusiastic in their level of care despite a number of the more senior
staff having moved elsewhere. A number of patients stayed a little longer
than usual given that they had come from a long distance and were not able
to return immediately given the availability of transport either by road,
sea or air.
Following the
team’s departure we were informed by Sr. Franseline that despite
suggestions by her to some of the patients that they could perhaps receive
treatment elsewhere, they all wanted to return to Cancar given the all
round quality of care provided by both the Cancar staff and the visiting
OSSAA team.
A small
number of burn contracture cases also presented, these being shared
between both the plastic surgical and orthopaedic surgical team for their
surgical treatment. These included a number of neck burn contractures,
but also contractures involving the hand. In addition there was one young
man who presented with significant burn contractures of the lower limb
producing adhesion of the legs to the thigh. This occurred bilaterally
producing a grave physical disability of gait. The release at the knee
was somewhat limited by shortening of the nerves and tendons, but was seen
as a first step in his overall rehabilitation. A further young child
presented with a major neck burn contracture. This was managed surgically
under a Ketamine anaesthetic initially converting this to a laryngeal mask
type intubation after completion of the burn contracture release prior to
the skin grafting. This young child will require a number of further
procedures given the extent of her burns both on the anterior neck and
lower face.
Upon the
team’s departure appropriate instructions were left with the local
physiotherapy staff to ensure splinting and mobilisation of these cases.
Among the 150
or more patients assessed in the plastic surgical clinical there were
again large numbers of lipomas and other soft tissue tumours. Many of
these were able to be excised under local anaesthetic with Dr Harianto
providing the backbone of this service. Over the first few days of the
week he was able to undertake these excisions on more than 30 patients.
This proved very beneficial in freeing up the visiting OSSAA surgeons for
the more complex cases. As noted previously, he remains an integral part
of the team and his skills and knowledge of the local conditions are much
appreciated.
the team had
the opportunity to review the two cases (FEME and maxillary tumour) who
had recently been in Adelaide for treatment. Both patients were well with
no post operative complications noted.
ORTHOPAEDIC SURGERY
The treatment
of musculoskeletal abnormalities have long been central to the activities
of St. Damian, with the orthopaedic surgical service playing a lead role
in this. The history of treatment of an array of clinical issues (club
feet, polio, leprosy and post traumatic deformities) at St Damian again
meant patients present from all over Flores and West Timor.
On this visit
once again a large number of patients with club feet were assessed and
treated. Ranging in age from 2 months to 30 years, the appropriate
surgical corrections were demonstrated with discussion and planning of
post operative splinting and programmes of rehabilitation with local
nursing and physiotherapy staff.
This
institution remains very well suited to continue as a centre of excellence
in the management of these significant orthopaedic complaints – a case can
be made for widespread referral here for both service and teaching, rather
than performing the surgery at all locations, where the appropriate post
surgical care may not always be available.
At the end of
the working week the team returned to Labuanbajo early on the Saturday
morning. With the planes departure for Bali at lunch time this allowed
the opportunity for the team to visit the more permanently disabled
children at Binongko. This was much appreciated by these significantly
disabled children, but also allowed the team to see the magnificent newly
constructed physiotherapy pool at the Binongko complex. This represents
yet another example of Sr. Virgula’s vision and organisational skills in
developing this project.
The
subsequent return home of the team was largely uncomplicated, other than a
minor issue with immigration at Denpasar airport. This in all
likelihood relates to an inappropriate visa being given to the team from
the Indonesian Consulate in Darwin. This matter will be addressed with
the Indonesian Consulate in the near future.
CLINICAL ACTIVITIES
Interventions
which enable patients to increase their productive capacity.
- Cleft Lip
and Palate Repair – included in the cleft cases assessed and treated
were a number of teenagers and adults whose clefts were unrepaired.
These patients had almost invariably been denied access to education on
the basis of their appearance. They also manifest almost intelligible
speech, poor dental hygiene and nutritional status.
- age appropriate surgical
repair in infancy and early childhood provides a clinical outcome which
encourages improved speech and dental development, normal nutrition and
the opportunity for education. Such surgery was possible in the majority
of cases on this visit
- Burn
Contracture Release – established burn contractures of the upper and
lower limbs and neck and face compromise aesthetics and function.
- surgical release and skin
grafting, followed by physiotherapy and splinting restores mobility,
manual dexterity and improves aesthetics. This allows improved capacity
for work and normal daily activities.
- Club Feet
Repair – untreated this deformity of the feet and ankles limits lower
limb mobility and predisposes to early degenerative changes and lower
limb disability.
- early surgical
treatment and post operative splinting and physiotherapy provides the
opportunity for lower limb mobility and function which permits a normal
working life.
TEACHING / TRAINING
- detailed
teaching of assessment and description of particular clinical
conditions. Identifying to community nurses and healthcare workers
clinical features of particular features of particular conditions (eg.
Cleft lip and palate, club feet etc), and timing of treatment; and
protocols and aftercare
- Teaching
protocols for post surgery splinting of club feet. Local
physiotherapists educated in programme of splinting for ongoing
treatment in the months following surgery.
Operating
Theatre
- Local
theatre nursing staff are already highly skilled in techniques such as
intravenous cannulation and skin suturing, and are encouraged to
maintain and practice these procedures with the visiting team.
- Local
surgical counterparts, such as Dr Harianto, routinely assist the
visiting surgeons and has over a number of visits been instructed in
surgical techniques of skin grafting, burn debridement, contracture
release, club foot repair, lower limb amputations etc.
-
Demonstration of the basic techniques of cleft repair was possible with
local dentist Dr Tommy. The role of lip and palate repair in minimising
the extensive dental anomalies associated with clefts was discussed.
-
Demonstration and teaching of post operative recovery principles to
local nursing staff is an ongoing part of training intrinsic to all
surgical visits.
- Sr. Angela
SSpS, who runs the equivalent surgical facility in Halilulik, West Timor
was an active participant in theatre. Demonstration of the
requirements, both instrument – wise and from the surgical technique
perspective was a valuable skill transfer opportunity which will assist
in the development of Halilulik
SUMMARY OF THE VISIT
Strengths
-
Ongoing support from the regional and provincial
governments.
-
Well developed network within the region which
produces an excellent triage assessment system such that a very high
percentage of the cases presented are appropriate for the individual
surgical specialties.
-
The consistency of the team personnel continues to
build the trust and commitment from our local counterparts.
-
The highest quality operating theatre and post
operative ward facilities.
-
A consistent level of counterpart health workers,
nurse and doctors.
-
Continued improved travel arrangements with a number
of airlines now providing transport into the region.
-
The commencement of a relationship with the nearby
Ruteng Hospital.
Weaknesses
- The
non-availability of Indonesian surgical trainee counterparts on this
occasion.
SUMMARY
OF CLINICAL ACTIVITIES
October
7 – 14, 2006
Total patient consultations
213
Plastic (Mr
Moore) 157
Orthopaedic (Mr
Keenan) 56
Total Surgical
Procedures 111
Plastic: 45
Clefts 42
(CL = 33, CP = 9)
Burns 2
Other 1
Orthopaedic: 32
Inc. (Burn 3
Other 6)
Local anaesthetic
procedures 34
SUMMARY
OF TEAM ACTIVITIES
October 6, 2006. Team members assemble in
Denpasar
October 7, 2006.
Team departs Denpasar for Labuanbajo, with onward road travel to
Cancar where met by SSpS nuns and staff. Patient consultations
October 8, 2006.
Outpatient consultations; visit to Ruteng Hospital for outpatientreviews.
October 9, 2006. Operations / consultations /
ward round
October 10, 2006. Operations / consultations /
ward round
October 11, 2006. Operations / consultations /
ward round
October 12, 2006. Operations / consultations /
ward round
October 13, 2006. Operations / consultations /
ward round
Farewell dinner
with SSpS sisters.
October 14, 2006. Team departs Cancar for
Labuanbajo.
Team undertakes short visit to Binongko before onward flight to Denpasar.
October 15, 2006. Team departs Denpasar for
Australia.
ACKNOWLEDGEMENTS
- Sr Virgula,
Sr Franseline, Sr Reginaldis, Sr Roberthilda and their fellow SSpS
sisters and staff of St Damian and St Rafael Hospitals for their long
term vision and dedication to maintenance of a dream.
- The
excellent support of the operating theatre and ward staff throughout the
lengthy days of work
- The NTT
Health Ministry, the Office of the Consulate of the Republic of
Indonesia in Darwin and the Bupati of Ruteng for their ongoing support
with visas and supporting documentation.
- Mr John
Maxwell and the ANTARA staff, Kupang for their assistance with this
project.
- The
numerous hospitals and medical suppliers, in particular Johnson and
Johnson for their support of the individual team members and the team as
a whole.
- The staff
of Garuda Indonesia and Pak Hendrik Tawir of Indonesia Air Transport for
their assistance in the team’s travel.
- The large
numbers of individuals and groups whose gifts and donations to the
patients in Cancar is so much appreciated by those receiving them.
- The
various team members and their families who remain dedicated to
supporting this work in Cancar.
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