O S S A A

OVERSEAS SPECIALIST SURGICAL ASSOCIATION OF AUSTRALIA

TEAM VISIT – CANCAR,

FLORES

SEPTEMBER 29 – OCTOBER 6, 2007.

TEAM LEADER’S REPORT 

DR MARK MOORE AM

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

In association with PERAPI (Indonesian Association of Plastic Surgeons)

AIMS AND GOALS

1.                  Maintenance of a regular, consistent reconstructive service to those patients with physical disability and deformity, both congenital and acquired in the region of Nusa Tenggara Timur (NTT), Indonesia.

2.                  The commencement of an Ear, Nose and Throat / Head and Neck surgical pilot programme to focus on the large number of untreated Head and Neck masses, and upper respiratory tract pathology in patients from the same region.

INTRODUCTION

The St Damian /St Rafael Hospital complex, Cancar, Flores is widely acknowledged locally and regionally as a centre of excellence in the delivery of surgical care, particularly for those with physical disabilities.  Having been established 40 years ago by St Virgula, SSpS as a leprosy clinic, it has now evolved into a multidimensional surgical and physical rehabilitation facility, providing an ideal environment for visiting surgical teams to perform their clinical activities and teaching.

Building on the pioneering leprosy and burn contracture surgery of Dr John Hargrave more than 15 years ago, the OSSAA surgical teams since 2002 have made 12 clinical visits to Cancar maintaining a regular and expanding range of surgical services and teaching,  Where the focus in recent years has been on cleft lip and palate, burn contractures and orthopaedic deformities, the teams have regularly seen patients with a broad range of head and neck tumours, for whom no local treatment is available,  A recent request from the St Rafael staff was also received for assistance in assessing the many children and adults with hearing problems, throat issues (enlarged, infected tonsils etc) and nasal deformity and obstruction (polyps etc).  The addition of an Ear, Nose and Throat surgeon to our team dovetailed in well with out recent attention to cleft lip and palate deformity in this region.

The local counterpart component of our teams was again composed of a balance of local and distant Indonesian medical and nursing staff.

Once again, PERAPI (Indonesian Association of Plastic Surgeons) nominated a young Plastic Surgeon to accompany our team to Cancar, and Dr Harianto, our long standing counterpart, proved valuable in undertaking the assessment and treatment of a large number of minor surgical excisions.  The availability  and active involvement of the local staff ensured the assessment, treatment and successful post operative management of both our usual cases and also a number of other more complicated head and neck surgical problems.

Despite the recent expansion of our OSSAA plastic surgical teams to Soe and Halilulik in West Timor, a large volume of patients were reviewed from all over Flores, as well as West Timor.   This resulted in a surgical workload which thoroughly tested the facilities of both St Rafael and St Damian.

Finally, this visit was the first to occur in the absence of St Virgula and St Franseline, who have been instrumental in organising and overseeing our team’s visits – they are both away from Cancar for an extended period, but in a testament to their preparing their replacements, the visit proceeded without any significant issues.

TEAM MEMBERS:

      Dr Mark Moore, AM                                   Plastic Surgeon/Team Leader

      Dr Suren Krishnan, OAM                           ENT / Head and Neck Surgeon

      Dr Harianto Hendrikus                              Leprosy Specialist - Sitanala

      Dr Magda  Hutagalung                              Plastic Surgeon, Surabaya

      Dr Philip Barnes                                        Anaesthetist

      Dr Tony Pearce                                         Anaesthetist

      Dr Yose Anggoro                                       GP /Resident - Jakarta

      Mrs Elizabeth Mazzei                                  Theatre Nurse

      Ms Penny Craig                                          Theatre Nurse

      Ms Ruth Boveington                                   Coordinator / Interpreter

      Counterparts:

      Dr Michael                                                 Resident GP St Rafael

      Sr. Reginardis SSpS                                   Operating Theatre Charge  RS St Rafael

      Sr Elsa SSpS                                              St Damian

      Sr. Daniella SSpS                                       St Rafael         

      Ibu Viktoria                                                Theatre Nurse - St Rafael

      Ibu Ernavati Kabora                                   Theatre Nurse - St Rafael

      Ibu Sabina Baun                                         Theatre Nurse - St Rafael

      Ibu Sofi                                                      Theatre Nurse - St Rafael

      Pak Ferdi                                                   St Damian

      Pak Nasrin                                                 St Damian

      Ibu Tanti                                                    St Damian

LOCATION

      St Damian and St Rafael Hospitals, Cancar, Kab. Manggarai, Flores, NTT

      With the departure of Sr Franseline, the local organisation and coordination of our   visit was in the hands of Sr Elsa, who is newly arrived in Cancar.  The specific request for ENT surgical services originated from Sr. Reginardis and hence the oversight of this aspect of the team’s work occurred largely with the staff of St Rafael.

OVERVIEW

This visiting OSSAA surgical team to Cancar involved the introduction of the first new surgical subspecialty additional to the long standing commitment to plastic and orthopaedic surgical services in this institution.  In response to local requests for such a service (large numbers of head and neck tumours, tonsillar problems, nasal obstruction etc.) and the availability of an ENT surgeon with experience working in the developing  world, the time was opportune to trial this surgical service in this environment.  By week’s end it was apparent that this visit had been an unqualified success - clinical assessment of a large number of adult and paediatric patients identified a high number with symptomatic tonsillar enlargement/infection,  and a broad array of head and neck tumours both benign and malignant, some of which were treatable locally.  The regional school for deaf and blind children, which is located nearby in Ruteng was visited and a clinic held.  Large numbers of cases in need of tonsillectomy have been waitlisted for surgery, after a small number were performed during this visit.

The local Indonesian doctor on his rural secondment to St Rafael , present on the teams previous visit, continues in his post.  He enthusiastically embraced the ENT surgical aspects of the visit – by week’s end he was a very able to perform a tonsillectomy in a safe and efficient manner.  Our teams input to his teaching over the last 2 visits will hopefully stand him in good stead for a future surgical career.

PERAPI, were at the last minute able to organise an Indonesian plastic surgeon to accompany the team.  Dr Magda Hutagalung, from the Dr Soetomo Hospital plastic surgical unit in Surabaya was again a very able and skilled clinician who greatly contributed to the large volume of plastic surgical cases treated.  It is to be hoped that this arrangement with PERAPI can be further refined with early bilateral communication regarding planned visits.

Dr Harianto as always made a significant clinical and organisational contribution to the team.  His ability to quietly and efficiently perform the smaller local excisions / local anaesthetic procedures left time for the rest of the team to focus on the larger and more complex cases.  He was also able to fulfil his commitment to the leprosy patients both in Cancar and Labuanbajo.

The teams arrival in Cancar was somewhat later than usual due to changes in airline timetabling for flights into Labuanbajo.  Merpati Airlines had only within the week prior to our arrival recommenced flying this route and with new planes.  The late arrival resulted in a short plastic surgical consultation clinic between 8.30 p.m. and 10.00 p.m. before dinner.

The next day ENT consultations proceeded in St Rafael with Dr Michael assisting Dr Krishnan – by day’s end over 100 patients had been assessed and preliminary operating lists constructed.  As the week progressed a significant number of patients with ENT problems continued to arrive, and Dr Krishnan was also able to visit the facility for deaf and blind children in nearby Ruteng where many were assessed and waitlisted for treatment on later visits.  Tonsillar enlargement sufficient to cause feeding and breathing difficulties were common, as were large obstructing nasal polyps – perhaps reflecting the local climate which is cool overnight and with a smoky atmosphere.  A broad array of head and neck tumours, from thyroid, to parotid gland,  tongue and nose p malignant and benign were assessed.  A patient with a small laryngeal cancer was referred with the help of Dr Magda to an ENT colleague in Surabaya – the potential difficulty of management of tracheostomy necessitating referral to a larger centre.

Large tumours in the parotid, thyroid and parapharyngeal regions were assessed and deemed able to by surgically managed in Cancar.  The patter patient’s tumour was impinging on his airway and requited placement of a tracheostomy under local anaesthetic.  This was successfully removed on the second post operative day.  Several cases required blood transfusions, given their vascular nature - this was anticipated and blood donors sought and tested.

The plastic surgical consultations continued throughout Sunday.  Over 100 cases were assessed, with once again the most common diagnosis being cleft lip and palate and burn contractures.  In parallel with this clinic Dr Harianto was assessing a large number of the more minor skin lesions / lipomas etc which were amenable to local anaesthetic excision – these he undertook over subsequent days.

Some 59 cleft lip and palate patients were assessed, with 47 of these having surgery on this visit.  Most were new cases having their primary surgery, including some for palate repair seen on our previous visits.  Once case needed minor lip revision in line with our practice in Australia.  Sadly, two cases who had received treatment elsewhere by visiting teams, needed complete re-do of their cleft lip and nose repair.  The cleft cases continue to come from far afield in Flores, and also some who missed our visiting teams were sent from West Timor.

One 19 year old woman was referred from near Atambua with both a bilateral cleft lip and palate and long standing neck / facial burn contracture.  Having been burned at age 4 years, she had received no treatment.  Seen by John Hargrave 10 years ago, an attempt was made to obtain treatment in Australia.  This never eventuated and she continued to grow, with progressive development of a facial skeletal deformity to accompany the soft tissue anomalies.   The surgery on this visit saw release and skin grafting of the neck contracture and repair of the cleft lip.  Post operative splinting and physiotherapy will be crucial to her outcome and also the need for further surgery in 6 months time.

The quality of the physiotherapy service locally was again reinforced by the outcome for the young male patient with burn contractures of both knees.  Released sequentially over the last two visits, with post operative physiotherapy, he has progressed from being ‘tethered’ to the floor to now walking and standing normally.

Buy week’s end the team had assessed over 400 patients and completed 149 operations.  The need for an ENT service was confirmed by the volume of cases and waitlist generated from a single visit.  The involvement of local medical counterparts ensured the transfer of skills and so upgraded both the knowledge and surgical skills of these young colleagues.  This cooperation with our Indonesian counterparts had also ensured that 3 patients seen on previous visits had been able to access treatment in Surabaya – this orchestrated by Dr Magda and he colleagues at R.S. Dr Soetomo.

This visit occurring during the dry season saw most patients in good health, with a lesser incidence of surgery cancellations or deferrals because of chest / upper respiratory infections.  One unusual deferral of surgery occurred in a female patient with severe facial burns in need of release of her oral commissure under local anaesthetic, who was also known to be pregnant – she delivered her baby on the morning of her planned surgery.

The team undertook final review of the patients and departed early on October 6 for Labuanbajo to connect with onward flights to Denpasar and then to Australia.

SUMMARY OF THE VISIT

STRENGTHS:

• Maintenance of support from regional and provisional governments.

• Support of PERAPI, with a further Plastic Surgeon  integral to the team.

• Expansion of clinical practice with successful trialling of an ENT service

• Maintenance of the excellent triage system – despite the transfer of Sr Franseline away from Cancar, the system of referral continues to work well.

• Consistently high quality operating theatre and post operative ward facilities
• Excellent local counterparts – Dr Hari, Dr Michael and Dr Magda.

• Indonesian Consul in Darwin for providing appropriate visas.

WEAKNESSES:

• Heavy clinical workload, produced challenges for local staff and facilities.

CLINICAL ACTIVITIES

The surgical interventions which result in increased productive capacity are:

• Cleft lip and palate repair  -  early repair results in the potential for normal speech, dental and facial development with resultant integration into normal schooling and society

• Burn contracture release  -  improved aesthetics and function is self evident with potential for normal physical capacity.

• Tonsillectomy / nasal polypectomy  -  improved nasal / oral airway with less chronic airway illness, improved schooling, education and work capacity.

• Head and neck tumour excision   -  prolongs life, provides maintenance of airway where untreated may compromise and obstruct vital functions

TEACHING  / TRAINING

• Local nursing staff / physiotherapists in management of patients following upper airway surgery, including tracheostomy.

• Assessment and management of common ear, nose and throat pathology for local staff, nursing and medical.

• Local rural GP assisted and taught to perform tonsillectomy.

• Ongoing interaction / discussions with visiting PERAPI plastic surgeons – ideally to become regular part of visiting team.

• Ongoing splinting / physio following burn contracture release.

• Maintenance of clinical / nursing standards in the operating theatre environment.

SUMMARY OF TEAM ACTIVITIES

September 28, 2007.                Team members assemble in Denpasar

September 29, 2007.                Team departs Denpasar on Merpati Airlines accompanied by Dr Harianto and Dr Hutagalung

                                                Arrive Labuanbajo, met by Cancar staff and onward road travel to Cancar

                                                Patient consultations commence.

September 30, 2007.                Outpatient consultations

                                                Preparation of operating theatre

October 1, 2007.                     Operations, consultations, ward round

October 2, 2007.                     Operations, consultations, ward round

October 3, 2007.                     Operations, consultations, ward round

October 4, 2007.                     Operations, consultations, ward round

October 5, 2007.                     Operations, consultations, ward round

                                                Farewell dinner with SSpS sisters.

October 6, 2007.                     Team departs Cancar for Labuanbajo before onward Indonesian Air Transport flight to Denpasar.

October 7, 2007.                     Team departs Denpasar for Australia

SUMMARY OF CLINICAL ACTIVITIES

SEPTEMBER 29 – OCTOBER 06, 2007

                       Total consultations:                                                    414

                  Total surgical procedures:                                          149

                 Plastic surgical procedures:                         59

                  Cleft lip / Palate                                               38

                  Cleft palate                                                      09

                  Burn contracture                                              11

                  Other                                                               01

                 ENT surgical procedures:                            31   

                   Tonsillectomy                                               14

                   Polypectomy                                                05

                   Thyroidectomy                                             02 

                   Cancers                                                       06

                   Other                                                           04

                 Local Anaesthetic procedures:                   59

ACKNOWLEDGEMENTS

• Sr Teresia, Sr Reginardis, Sr Elsa 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  week’s work.

• The Bupati of Ruteng, the NTT Health Ministry and the Office of the Consulate of the Republic of Indonesia in Darwin for their ongoing support of documentation and visas for the team’s work.

• Pak Hendrik Tawir of IATA for his organisation of the team’s travel in Indonesia.

• Johnson and Johnson (David Carney and Tyson Osborne)

• Tyco (Emily Molner and Eleni Argyriou)

• Abbott Pharmaceuticals (Mark Ritchie)

            The above three for their provision of surgical and anaesthetic consumables

• Calvary Healthcare North Adelaide, Burnside and St Andrews private hospitals for their aid and support with supplies both surgical and anaesthetic.

• Those others, both family and friends of OSSAA whose gifts and support ensure the ongoing success of the team in Cancar.

 Please use the 'Back' Button to return to the last page