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OVERSEAS SPECIALIST SURGICAL ASSOCIATION OF AUSTRALIA
ANTARA – RACS NTT PROJECT
TEAM VISIT – CANCAR & RUTENG, FLORESMARCH 17 – 24, 2007.
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
In association with PERAPI (The Indonesian Association of Plastic Surgeons)
AIMS AND GOALS1. 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. The introduction of a speech pathologist to the team with the aim of building and expanding upon the cleft lip and palate treatment service available at the St Damian/St Rafael Hospital complexes. INTRODUCTION:
The assessment and treatment provided by this OSSAA based Plastic and Reconstructive Surgical team at the St Damian / St Rafael Hospital complex, Cancar, Flores is the extension of a programme first commenced by Dr John Hargrave, leprosy and burns surgeon from Darwin. It is now approximately 15 years since Dr Hargrave first began his work in this region.
This visit represents the eleventh clinical visit undertaken by OSSAA teams to the St Damian Hospital where a broad range of physical disabilities and deformities are surgically managed and followed up.
Since the last visit in October 2006 a number of the ANTARA/RACS based surgical teams have undertaken work elsewhere in Flores, although none of these have included a Plastic and Reconstructive Surgical component. The team’s visit however was not undertaken directly under the umbrella of ANTARA.
The teams visiting Cancar have in recent years made a concerted effort to add a significant teaching component to their clinical service. Thus in addition to local Indonesian doctors in the region, the team has sought to involve Indonesian Plastic Surgeons with their team. This has meant ongoing communication with PERAPI, the Indonesian Association of Plastic Surgeons. Indeed, PERAPI has requested ongoing communication regarding the activity of visiting teams such as ours. As a consequence, the team was fortunate to have with it on this occasion a recently qualified Plastic Surgeon from the major teaching hospital in Surabaya. Our long standing counterpart Dr Harianto was not able to accompany the team as he was working with a similar OSSAA team in Soe, West Timor.
As with each previous visit the St Damian complex continues to flourish and develop. Recent changes in health care provision in Indonesia for the poorest patients meant that they can now access the St Rafael portion of the complex. This allowed on this occasion for a sequential movement of patients during the post operative period from those wards where close supervision can be performed on the first night post operatively, through to those areas of the complex where less intense post operative supervision is available on subsequent nights.
As with previous visits patients continue to attend for our team’s visit from areas widely across Flores with also a number of patients coming from West Timor. This occurred despite the fact that there was relatively little advertising of the team’s presence through the usual networks. TEAM MEMBERS
Dr Mark Moore Plastic
Surgeon / Team Leader Dr Markus Nikitins Plastic Surgeon Dr Magda Hutagalung Plastic Surgeon / Surabaya Dr David McLeod Anaesthetist Dr Tony Pearce Anaesthetist Sr. Margaret Maloney Theatre Nurse Mrs Roslyn Sells Speech Pathologist Ms Ruth Boveington Coordinator / Interpreter
COUNTERPART STAFF, ST DAMIAN/ST RAFAEL HOSPITALS
Sr. Reginaldis SSpS Operating Theatre – in charge Dr Michael Local Cancar Doctor Sr. Angela SSpS Medical student/nurse anaesthetist Ibu Sabina Bavu Theatre Nurse Ibu Ernavati Kabora Theatre Nurse Ibu Sofi Theatre Nurse Pak Dony Theatre Nurse Sr. Franseline SSpS Ward and Outpatients – in charge Ibu Tanti Ward Nurse/physiotherapy Pak Ferdi Ward Nurse/physiotherapy Pak Nasrin Ward Nurse/physiotherapy
LOCATION
As with all previous visits the local organisation and notification of patients was supervised and coordinated by Sr. Franseline SSpS, who in advance of the team’s arrival communicates directly with Ruth Boveington, Team Coordinator and Interpreter.
As noted above, the post operative care on this occasion occurred in a sequential fashion, initially with patients on the first post operative night being cared for in the St Rafael complex. Thereafter the patients progressed to the St Damian area where the nursing care was less intensive. Those patients with burn contractures requiring longer term treatment were managed post operatively in the St Damian area where splinting and physiotherapy can be overseen.
OVERVIEW
The visiting OSSAA surgical team to Cancar for this visit was a pure plastic and reconstructive surgical team. It had been planned to bring an orthopaedic surgeon, but their unavailability at this time meant that the team chose to bring two Australian Plastic Surgeons with one surgeon undertaking his first visit. It also provided the opportunity for close interaction and discussion of difficult cases with our visiting Indonesian Plastic Surgical colleagues.
The team was also fortunate on this occasion to strike a young Indonesian doctor whose rural service had brought him to Cancar and who was also enthusiastically planning for a surgical career.
The team was informed that there had not been extensive widespread advertising of the visit, particularly in West Timor where an OSSAA team was also visiting at the same time. As the West Timor team also included a plastic surgeon who had expertise in cleft lip and palate surgery, it was hoped that most of those patients could be managed in West Timor. Despite this, the team did assess 130 patients with a very high proportion of these patients being entirely appropriate for assessment and treatment by this team.
The initial consulting session commenced late on Saturday afternoon after the team’s arrival from Labuanbajo.
The travel from Denpasar and then by road from Labuanbajo was largely uneventful with there having been close communication with the representative of Indonesia Air Transport, the airline which now flies the route between Denpasar and Labuanbajo. He is a supporter of our team and has made a point of ensuring our air travel arrangements were uncomplicated.
The consulting session assessing patients continued through most of Sunday after the initial 2 – 3 hour session on Saturday night. At the completion of Sunday’s consulting session the theatres were reviewed and one of the anaesthetists who was on his first visit to Cancar had time to familiarise himself with the theatre and anaesthetic machines. Full operating theatre lists were constructed so as to utilise both theatres.
The team was also asked to see 4 patients who were already inpatients in the St Rafael wards. From these patients, two presented with clinical problems which were amenable to surgical correction. The remaining two patients included a child with a cystic hygroma in the neck which at this time does not require any intervention. The last patient was a 23 year old female with a large aggressive subcutaneous tumour mass extending widely across her back and into the neck to involve the brachial plexus. This tumour was inoperable and unfortunately no other treatment options were available.
The operating theatre complex, as on the previous visit, was immaculately maintained. The piped supplies of oxygen and nitrous oxide were well maintained and the usual Soft Lander anaesthetic machines were present. The team’s anaesthetists had brought with them Isofluorane which was used through the existing vapourisers on these anaesthetic machines.
The surgery undertaken by this team was largely similar to that which has been undertaken on previous visits. The backbone of the work was again cleft lip and palate surgery. Approximately 45 cleft lip and palate patients were assessed and 39 of these cases went on to have surgery during the week. A number of the new cleft lip and palate cases from Maumere that presented in November 2006 returned on this occasion for the palatal surgery after having had the lip surgery in November. This occurred without formal notification having been sent to Maumere.
At the completion of this visit the team has now performed some 299 cleft lip and/or palate repairs. Included in the 39 cleft repairs were 2 rare Tessier facial clefts, these being unusual clefts extending from the lip around the base of the nose up towards and involving the lower eyelids. These cases represent a more complicated reconstructive challenge and following repair of the soft tissue element will need later bony and further soft tissue surgery.
Post operative management of all cleft cases on this visit was satisfactory without any early complications noted.
The addition of a Speech Pathologist to our team saw her involved with the patients and parents, introducing some of the basic concepts related to feeding and sound production in cleft patients. It also provided the opportunity for discussions with the parents about options for feeding in the cleft lip and palate patient and how these might differ from what is available in the developed world. A more detailed report on this aspect of the visit will be provided separately by Ros Sells.
A number of the long term burn contracture patients returned for further release and skin grafting. In addition, a number of new burn contractures were presented. This included a 6 year old girl who presented with burn contractures involving both axillae, such that the arms were fused to the chest wall and more significantly, both thighs were fused together and flexed and adherent to the lower anterior abdominal wall. Given the extent of the contractures and the amount of grafting required, it was decided to focus on the lower limbs and abdominal wall contractures. This allowed separation of the thighs from one another as well as release of the flexion contractures in the region of the hips. Extensive grafting was required over the medial aspect of the thighs and lower anterior abdominal wall.
On the previous visit a young male patient presented with bilateral contractures in the region of the knee such that the legs were fused to the thighs. Wide release was undertaken of one leg at that time, allowing the knee joint to be opened to approximately 90 degrees. With aggressive physiotherapy by the staff at St Damian, this leg has now been extended almost straight such that he can now weight bear on this leg. On this visit the opposite leg had the same release procedure with skin grafting and it is to be hoped that he will achieve the same degree of improvement with the post op splinting and physiotherapy.
These cases continue to present given the prevalence of lamps and kerosene cookers in the developing world, as well as relatively poor quality clothing and the lack of access to adequate burn nursing care.
Of interest on the last day was a young man previously seen on the ward presenting with a large exophytic tumour on the central back. This had been present for about 11 years and the exact pathology was unknown. It became evident that whilst this tumour was large, it had a less extensive base and the decision was made to proceed to wide excision with skin graft of the resulting defect. The tissue from this tumour was brought back to Adelaide for definitive pathology as were a number of other smaller tumours either removed or biopsied.
During the week the team also had the opportunity to meet with Valeria Cundawan who had a month previously been in Adelaide for surgical correction of her fronto-ethmoidal meningo-encephalocele. As she lives in a region near to Cancar she will be reviewed once again in 6 months time.
The only difficulty the team experienced during the week related to the new class of visa the team enters into Indonesia under. This presently has a requirement that the team should present themselves to the provincial immigration office as the team enters through Bali but then moves to NTT. As this office is in Maumere some 12 hours drive away, this is not technically possible for the team. The SSpS sisters organised for a priest to take the team’s passports to the Maumere office where the appropriate paperwork was undertaken. This remains a difficult logistical exercise and it is to be hoped can be sorted out prior to the next visit.
The visiting Plastic Surgeon from the Dr Soetomo Hospital in Surabaya played an active role in the team both in operating and in assisting in both assessment and post operative care of all patients. As with previous Indonesian Plastic Surgeons on the team this provided an excellent opportunity for discussion of difficult clinical problems and allowed each of us to better understand the practice of plastic and reconstructive surgery in our respective countries. Dr Magda also offered to assist in the treatment of a number of patients with difficult tumours which need surgical and post operative facilities greater than can be provided for in Cancar. It is to be hoped that these cases can be arranged to be transferred to her hospital plastic surgical unit in Surabaya.
The team on March 24 travelled to Labuanbajo before onward air travel to Denpasar.
CLINICAL ACTIVITIES
Interventions which enable patients to increase their productive capacity.
· Burn Contracture Release – The surgical release and skin grafting, followed by physiotherapy and splinting restores mobility, manual dexterity and improves the aesthetics. As demonstrated by a case operated on on a previous visit whose range of movement was improved by the physiotherapists this skill is already present in Cancar with a number of staff well trained in this area. Ongoing treatment of such cases as part of this team approach will continue to expand this skill base.
TEACHING / TRAINING
As noted above, this visit involving two Australian Plastic Surgeons and one Indonesian Plastic Surgeon provided and excellent opportunity to share ideas, to learn about one another’s training and clinical practices and for more general knowledge transfer.
The exposure of a young local Indonesian doctor to the spectrum of practice of the visiting team provides a stimulus and focus where this individual wishes to explore a career in surgery as in this case.
Similarly one of the nurses in the theatre complex was in fact a visiting SSpS sister presently a medical student at University in Jakarta. This also provided her with an opportunity to work with the team and be exposed to the practice of anaesthesia and surgery.
Operating Theatre
SUMMARY OF THE VISIT
Strengths
Weaknesses
SUMMARY OF CLINICAL ACTIVITIES March 17 - 24, 2007
Total patient consultations 130
Total Surgical Procedures 69
Clefts 39 Burns 11 Other 19 Cancar Surgical Database
February 2002 – March 2007.
11 Clinical Visits
Total Consultations: 1717
Total Surgical Procedures: 805
Cleft Surgery 299
Cleft lip 245
Cleft Palate 54
Burn Surgery 89
SUMMARY OF TEAM ACTIVITIES
March 16, 2007 Team members assemble in Denpasar
March 17, 2007. Team departs Denpasar accompanied by Dr Magda for Labuanbajo, with onward road travel to Cancar where met by SSpS nuns and staff. Patient consultations commence
March 18,
2007. Outpatient consultations. Assessment of the operating
theatre complex
March 19, 2007. Operations / consultations / ward round
March 20, 2007. Operations / consultations / ward round
March 21, 2007. Operations / consultations / ward round
March 22, 2007. Operations / consultations / ward round
March 23, 2007. Operations / consultations / ward round Farewell dinner with SSpS sisters and staff
March 24, 2007. Team departs Cancar for Labuanbajo before onward flight to Denpasar. ACKNOWLEDGEMENTS
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