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TEAM VISIT – TIMOR LESTE NOVEMBER 10 – 17, 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, consistent, dedicated plastic and reconstructive surgical clinical service to the people of Timor Leste, employing personnel with a commitment to this region.
2. Active participation in the teaching and training of our counterpart East Timorese surgical, anaesthetic and nursing staff at the Hospital Nacional Guido Valadares in Dili.
3. An ongoing commitment to the continued expansion and evolution of a wide community based referral network for those patients with physical disability and deformity, ensuring their ability to access both the surgical treatment and appropriate ongoing post surgical therapy and rehabilitation. INTRODUCTION
This OSSAA/RACS Plastic and Reconstructive Volunteer Surgical Mission to Timor Leste represents the eleventh visit undertaken as part of the AusAID sponsored RACS East Timor Surgical Specialist Surgical Specialties Project.
Occurring in November 2006, the visit proceeded in a climate of significant social and political upheaval within Timor Leste. Indeed the preceding team witnessed the first episodes of violence and property damage and destruction as it left Timor Leste in May 2006. In the intervening period ongoing violence and damage to both persons and property, particularly within Dili, has seen the displacement of large numbers of people from their homes, widespread destruction of homes and establishment of a number of refugee camps within the urban area of Dili. This included a large refugee camp within the confines of the Nacional Hospital in Dili where a large number of the nurses have lost their homes and have relocated to UNHCR tents in the hospital compound.
In anticipation of this significant social upheaval several members of the previous team felt uncomfortable about proceeding with elective surgery. After discussions with members of RACS, including the resident RACS team leader in East Timor as well as a number of our local counterparts of long standing, it was decided to proceed with this visit, knowing that the overall clinical activity may be down somewhat on previous visits. In light of some expected difficulties with travel in the present climate, it was decided to concentrate the clinical service in Dili with accompanying clinics in Aileu and at the Bairo Pite Clinic in Dili. It had previously been contemplated that the team visit Oecussi, but with the smaller team size and the difficulties with travel it was not possible to proceed with this on this occasion, but this remains an option for future visits. TEAM PERSONNEL
Personnel included in the team were:
Dr Mark Moore Plastic Surgeon/Team Leader Dr David McLeod Anaesthetist Sr. Margaret Maloney Operating Theatre Nurse Ms Ruth Boveington Coordinator/interpreter
LOCATIONS AND COUNTERPARTS
Ms Eileen Velicky – Physiotherapist m Bairo Pite Clinic (Dili) Dr Dan Murphy – General Practitioner
Aileu Clinic Mr Rogerio de Conceição – Nursing Clinic Manager
Hospital Nacional Guido Valadares – Dili Dr Eric Vreede – RACS Resident Team Leader/anaesthetist Dr Robert Black – RACS Resident Surgeon Dr Joao Pedro – Surgical Trainee Dr Ivan – Cuban Resident Maxillofacial Surgeon Mr Nicolau – Anaesthetic Nurse Mr Amano – Anaesthetic Nurse Mr Tino – Anaesthetic Nurse Mr Faustino – Instrument Nurse Mr Sarmento Correia – RACS Coordinator
PAS Clinic – Dili Sr. Maria Dias – Nursing Clinic Manager
Despite the difficulties in Timor Leste at the time of this visit the RACS Coordinator, Mr Sarmento Correia had made a conscious effort to communicate the team’s time table to the local community. This ensured that the people of Baucau were informed that the team would not on this occasion be visiting, thus avoiding disappointment to patients in the eastern region. It also ensured that there was a reasonable turn up in the Outpatient area of Dili Hospital despite the number of refugees being present in the vicinity.
For those patients in Dili who were concerned about presenting to the hospital, the opportunity to see these patients at Bairo Pite Clinic was a solution and a means by which they could be reassured that it was safe to then come to the hospital for surgical treatment. Similarly, a number of patients from Ermera presented in the Aileu Clinic as a precursor to then travelling down to Dili for surgical treatment.
The team also had the opportunity to meet with Dr Tim Keenan, Orthopaedic Surgeon, who was visiting East Timor briefly.
The team also received a number of pathology specimens from Baucau as part of its ongoing commitment to support the work of Dr Philip Mwaura in Baucau. OVERVIEW
The usual pattern of clinical assessment and subsequent surgical treatment continued with this visit, despite it being a smaller team, the surgical treatment being limited to work in Dili. Arriving at the Hospital Nacional Guido Valadares it was quickly apparent that it was not functioning in a fashion that the team has experienced previously. The first visual impression of the hospital being full of UNHCR tents erected on most of the open spaces between the wards and theatre, with large numbers of refugees living within the confines of the hospital created an environment that was quite surreal. Similarly in the Outpatient Clinic it was difficult to determine who were patients to be seen and who were in fact refugees living on the adjacent open spaces. Adjacent the Outpatient Clinic a temporary shop had been erected to cater and provide for the refugees who were cooking and preparing food almost on the doorstep of the Outpatient Clinic.
Despite these limitations a
significant number of patients presented for assessment including some
that had been seen on previous visits and waitlisted for treatment on this
occasion. The spectrum of patients assessed at the Dili Hospital were as
on previous visits, very appropriate to our specialty. Given the
frequency of our visits, it is now well established as to the range of
conditions that are managed by this team. In addition, several members of
the East Timorese Police Force who were shot in an incident earlier in the
year and surgically managed in Adelaide were seen for review, the nature
of their injuries being primarily orthopaedic. Arrangements were made for
follow up Xrays and then for review by the Resident Orthopaedic Surgeons
in Dili. Outreach clinics were held in Aileu with the Maryknoll Sisters and also at the Bairo Pite Clinic with Dr Dan Murphy. In Aileu a number of patients were assessed who had arrived from Ermera, these patients being somewhat concerned about travelling to Dili. Amongst this group were at least four older patients with cleft lip and palate and it was possible to reassure them that it was safe for them to proceed to surgery and that this was organised to occur on the first day so that as a group they could present to the hospital and that following surgery they could equally leave as a group with some feeling of comfort and safety. Whilst in Aileu the opportunity was taken to visit the prosthetic clinic there, established by the Maryknoll Sisters and managed by Bill Velicky. This set up employs 4 local staff who have now designed and are constructing wheelchairs for the disabled. The 4 workers all have significant physical disabilities themselves and are producing a high quality product virtually from scratch which is ideal for the environment in East Timor.
The clinic at the Bairo Pite Clinic went ahead on the Sunday. It would appear that many people in Dili feel threatened by the present situation at the main hospital and are using the Bairo Pite Clinic as an alternative. It has thus expanded somewhat and is interestingly in receipt of considerable support from a number of volunteer service organisations. Some 18 patients were seen at the Bairo Pite Clinic, a number of which were booked on lists for surgery the coming week.
When reviewing the distribution of patients generally it would appear that most attending the clinics came from the Dili area or the immediately adjacent districts. There were no patients who travelled from the Baucau or eastern region. There was a single patient from Suai and none from Oecussi nor Atauro. This is I think generally reflective of the concerns about the present situation in Dili.
The team once again saw a large number of clefts on this visit – a further 20 new referrals, bringing to 57 the number of new cleft referrals in the calendar year 2006 and a total of 468 cleft patients on the existing database since 2000. The range in age on this visit was between 2 weeks and 21 years. It was possible to operate on a child as young as 2 months and the oldest untreated cleft was aged 21 years. Amongst the 17 cleft patients operated on, 2 had previous surgery and needed significant revisions, but all other cases were newly treated cases. The surgery on these cases proceeded uneventfully with all being discharged within one or two days of surgery with appropriate follow up instructions.
The other significant clinical input on this visit involved the management of burns and burn contractures. A female patient with a significant burn contracture of the neck treated on the most recent visit, represented. She has achieved a dramatic correction of her neck contracture by dent of her dedication to physiotherapy and splinting of the neck following previous release and split skin grafting. On this occasion she underwent release and skin grafting of her left elbow contracture and was given similar instructions regarding her post operative management.
Within the hospital was an unfortunate 16 year old who sustained full thickness burns across the full extent of her anterior thorax, extending onto the neck and lower portions of the face bilaterally. This burn had been previously debrided and attempted skin grafting undertaken, the latter unfortunately having failed due to ongoing infection. This young lady was initially dressed in the operating theatre with the assistance of the local surgical staff and arrangements were made for a programme of skin grafting to commence during the week. Accordingly, skin grafts were placed to the region of the face and neck in an attempt to minimise the ongoing contracture in this region. By weeks end the graft appeared to be stable and advice was provided to the resident surgical staff regarding a programme of ongoing skin grafting for this young lady. In addition, recommendations were made regarding her nutrition and feeding.
The management of these significant burns remains a major issue in East Timor and consideration could be given to a programme being run for basic burn care for both the nursing and surgical staff. Members of the nursing and surgical staff have been in Australia for a programme of burns treatment, but this was curtailed earlier this year when the trouble broke out. Given the limited availability of consumables for burn management, it would seem more appropriate that a course be held in East Timor and the approaches be tailored to the available resources in East Timor.
Support for the team’s work in Dili Hospital from the local staff showed quite a marked degree of variability. All our patients were treated in the usual surgical wards on this occasion and within the limits of the present circumstances was generally of an acceptable standard. As noted above the arrangements for care of acute burns remains somewhat substandard, but some discussions were held with the head of the nursing staff in the women’s surgical ward regarding how this can be progressed.
Within the operating theatre complex the anaesthetic nurses provided an exceptional support to the team with a high level of professionalism and dedication to their profession and care for their fellow Timorese. Unfortunately with the surgical and instrument nurses this same level of commitment was not demonstrated. Where anaesthetic nurses were available for all cases operated on within the theatre complex, on only one occasion was a local operating theatre nurse available and scrubbed for the team during the week. A variety of explanations were provided to the team about this non-involvement. The visiting team’s disappointment at this lack of commitment from the local nursing staff was communicated to them and the loss of the teaching opportunity that is availed by visiting teams was to be regretted. It is to be hoped that with improved leadership the situation in the operating theatre can be improved.
The surgical team did receive excellent support from Dr Joao Pedro, the East Timorese Surgical Trainee, who had only days before returned from a period of training in Papua New Guinea. In addition, excellent support was provided by Dr Ivan, the newly arrived Cuban Maxillofacial Surgeon who expressed a particular interest in the management of cleft lip and palate. Organisational and administrative issues requiring further comment include:
1. Air travel to and from Timor Leste
The travel arrangements to Timor Leste on this occasion presented no specific difficulties. Appropriate communication from RACS to Qantas and Air North ensured that there were no difficulties with excess baggage on the trip to Dili. Unfortunately on leaving Dili excess baggage was charged for the return of our surgical instruments. The possession of a letter from Air North explaining the waiver for excess baggage would be helpful as at the Dili end ticketing is done in a manual fashion and any agreement arranged from the Australian end is not necessarily transmitted to the Timorese end. With the identification badges provided there appeared to be no difficulty in passing through immigration and no attempt to charge any team member a visa fee.
2. Accommodation and meals in Timor Leste
The accommodation was once again arranged at the Hotel Turismo. All team members were based in single rooms which unfortunately did not possess either a refrigerator or television. The rooms were otherwise satisfactory and safe. The team as able to obtain meals at a number of sites within Dili and despite some limitations on travel had no difficulty in travelling to and from these restaurants.
3. Travel and transport
The team was fortunate enough to again have access to a vehicle, on this occasion being provided by Rentlo. With Thrifty Car Rentals having now left Dili and their business at least being partly taken over by Rentlo it was much appreciated by the team that an arrangement similar to that which existed with Thrifty in the past was once again provided. The support of Rentlo for our team is very highly appreciated and it is to be hoped that this can be continued with subsequent visits.
4. Hospital facilities / staff / communication
a. RACS Coordinator
On this visit Mr Sarmento Correia is to be commended for his having achieved a highly satisfactory and appropriate patient turn out despite the present social turmoil. With 77 patients presenting to the team this provided a workload that was quite appropriate for the team for the week. Similarly the communication through to Baucau that the team would not on this occasion be visiting ensured that no patients were disappointed in that area. The team hopes that this communication network can continue to flourish and that with appropriate organisation the team will be able to further expand its network outside of Dili and Baucau on future visits with preliminary discussions again being held on the possibility of travelling to Oecussi.
It was also pleasing to see Mr Sarmento with the team in Outpatients in Dili and visiting and interacting with the team during the week, as well as assisting with negotiations relating to some of the difficulty with theatre staff. His role as a support to the team and a means of interacting with the permanent staff is a role that he appears to be growing slowly into.
b. Outpatient Clinics
As noted previously, the Outpatient Clinic at Dili Hospital proceeded smoothly despite the difficulties of the immediate surrounds. The numbers were slightly reduced in terms of the number of patients turning up at the clinic, but this was entirely explicable given the other issues within the society. There is a consistency of personnel in the Outpatient Clinic and they have come to know well the team’s approach and requirements.
c. Operating Theatre
As has been detailed above, it was within this environment that significant issues occurred. Whilst the anaesthetic nurses performed at the highest level and showed a level of commitment well above what was expected, the same could nor be said for the nurses locally described as instrument nurses. Discussions were held with the head of the operating theatre, Pak John, but this produced no satisfactory explanation as to why they were unwilling to work with our team. With the absence of strong leadership within the theatre environment and seemingly an inability of the Hospital Director to influence this, the real opportunity for these nursing staff to further develop their skills is being lost. Whilst our team can function quite satisfactorily without the local nursing staff in much that it does, the principal is that such aid missions are a bilateral relationship with some commitment from the local staff to this whole process.
d. Surgical Ward Post Operative Management
During this visit there were no issues relating to the surgical wards. The cleft patients were all managed post operatively without complication and beds were found for all patients, albeit on occasion this being in the ward corridors.
As has been noted above, the management of acute burns remains a real problem for Timor Leste. Major limitations with regard to simple wound care, dressing techniques, as well as limitations in the availability of consumables limits the ability to treat major burns. The head of the female surgical ward has had some exposure to burn care management in Australia, but does I believe need further help and direction.
e. Medical Staff
The team received excellent support from both the resident RACS anaesthetist and surgeon and also from the other resident medical staff within the hospital.
Of particular note with regard to the training of Timorese surgical staff, Dr Joao Pedro was actively involved with the team. His confidence level appears to have improved since his return from PNG and it is hoped that we can encourage him to continue to work effectively with our teams. The patient with the significant burn was left in his hands in terms of further managing her following the team’s departure. It is to be hoped that his commitment to this patient will translate to a positive outcome for the patient.
On this occasion the team also received help from Dr Ivan, the newly arrived Cuban Maxillofacial Surgeon. He has some considerable theoretical knowledge regarding the management of cleft lip and palate and appears keen to undertake such surgery himself. The team pointed out to him the importance of a high level of anaesthesia for a successful outcome in cleft surgery and it is to be hoped that this lesson has been absorbed. VISIT ASSESSMENT
Strengths
Weaknesses
CLINICAL SUMMARY – NOVEMBER 10 – 17, 2006
Total Patient Consultations: 77
Aileu 12 Bairo Pite Clinic 18 Hospital Nacional Guido Valadares 47
Total Surgical Procedures: 33
Cleft lip 14 Cleft palate 03 Burn/burn contracture 05 Others 11 SUMMARY OF TEAM ACTIVITIES – NOVEMBER 10 – 17, 2006
Consultation clinic with the Maryknoll Sisters in Aileu
November 11, 2006. Remaining team members arrive in Dili Outpatient clinic held in Hospital Nacional Guido Valadares, Dili
November 12. 2006. Consultation clinic at Bairo Pite Clinic, Dili Some members of team visited Becora District and watched a reconciliation soccer match in progress
November 13, 2006. Surgical procedures, Dili Hospital
November 14, 2006. Surgical procedures, Dili Hospital
November 15, 2006. Surgical procedures, Dili Hospital
November 16, 2006. Surgical procedures, Dili Hospital
November 17, 2006. Final ward round at Dili Hospital Part of team depart Dili for Darwin, remainder of team depart Dili for Bali and a meeting in Jakarta ACKNOWLEDGEMENTS
MARK MOORE, FRACS PLASTIC AND CRANIOFACIAL SURGEON
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