OVERSEAS SPECIALIST SURGICAL ROYAL AUSTRALASIAN ASSOCIATION OF AUSTRALIA COLLEGE OF SURGEONS
AUSTRALIA TIMOR LESTE PROGRAMME OF ASSISTANCE SPECIALIST SERVICES (ATLASS)
TEAM VISIT – TIMOR LESTE
OCTOBER 19 – 27, 2007
TEAM LEADER’S REPORT
DR. MARK MOORE AM MB,ChB, FRACS PLASTIC AND CRANIOFACIAL SURGEON
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 volunteer surgical mission are as previously specified:
1. Providing a regular, ongoing plastic and reconstructive surgical clinical service to the people of Timor Leste, utilising 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 both the Hospital Nacional Guido Valadares, Dili and Hospital Referral Baucau, Baucau
INTRODUCTION
This OSSAA/RACS Plastic and Reconstructive volunteer surgical mission to Timor Leste is the 22nd such undertaken by this group and organisation since the beginning of this regular work in early 2000. The visit is the 13th under RACS administration and the 2nd as part of the ATLASS project which began in late 2006.
The visit follows on some 4 months after our delayed July visit, which occurred just before the further disturbances after the parliamentary elections in late June. Following this brief period of unrest the country had settled satisfactorily such that the team felt able to provide a two surgeon input and allow coverage again of both Dili and Baucau hospitals.
Whilst much of the July unrest had occurred in and around Baucau, by the time of the team’s arrival on this occasion the region seemed well settled and the hospital continued to function in much the same fashion as the team had last experienced one year before. The same could not be said for the Hospital Nacional Guido Valadares in Dili, where considerable renovation and reconstruction is underway. Complete dismantling of the administration block as well as all the surgical wards creates considerable disruption to the running of the hospital and has somewhat altered the ability of the teams to function satisfactorily in Dili.
Despite these disturbances, the team once again made a useful contribution to both the clinical and teaching aspects of this programme in Timor Leste.
TEAM PERSONNEL
The visiting team was as follows:
Dr Mark Moore Plastic Surgeon/Team Leader Dr Peter Hayward Plastic Surgeon Dr David Sainsbury Anaesthetist Dr Eric Vreede Anaesthetist Sr Penny Craig Operating theatre nurse Sr Josie Luke Operating theatre nurse Sr Helen Roberts Recovery/anaesthetic nurse Ms Ruth Boveington Coordinator/interpreter
On the eve of the team’s departure to Timor Leste, Dr Elizabeth Freihaut, an anaesthetist from Darwin, fell ill and was unable to travel with the team. This necessitated some rearrangements and the good services of Dr Eric Vreede, resident RACS team leader and anaesthetist in Dili, were utilised to ensure that the team could function normally.
COUNTERPARTS
DILI Counterparts:
Mr Sarmento Correia RACS Coordinator Mr Fransisko Scrub Nurse Mr Andre Moises Scrub Nurse Mr Nicolo Anaesthetic technician
BAUCAU Counterparts:
Dr Phillip Mwaura Resident Surgeon Mr Antonio Correia Nurse in Charge – Operating theatre Mr Anselmo Anaesthetic Technician Mr Valerio Anaesthetic Technician Mr Fransisko Anaesthetic Technician Mr Mateus Instrument Technician Mrs Carmina Scrub Nurse Mrs Regina Scrub Nurse Mrs Tina Scrub Nurse
OVERVIEW
The members of the reconstructive surgical team arrived in Dili on consecutive days of 19 and 20 October. The team leader and coordinator arriving on Friday, were able to confirm accommodation arrangements and arrange for the availability of vehicles for the team to function within Dili and also to travel to Baucau. In addition, prior communications had set up a meeting with ASSERT, the community based rehabilitation service based in Becora in Dili. A meeting was held with Louise Maher and Ms Dulcie, the present coordinator of ASSERT. Whilst this meeting was initially to do with management of a burn patient in need of surgery and post operative care, it did allow the team to once again view the complex at ASSERT and discuss with staff their availability to provide ongoing rehabilitation for a number of the plastic surgical cases.
The remainder of the team arrived on Saturday morning and following a brief discussion, the appropriate changes in personnel were made to cover for the loss of one of our anaesthetists. With the need for Dr Vreede to stay in Dili, it was agreed that Dr Sainsbury would accompany the team to Baucau with Helen Roberts acting as the nurse for the team in Baucau whilst the two theatre nurses remained in Dili with Dr Hayward.
Later on Saturday morning the complete team travelled to Dili Hospital where an outpatient clinic was undertaken. Whilst arriving at the hospital in its present state of disrepair was the cause for some disquiet, arrival in the outpatient department was even more concerning to seeing this whole area remains a refugee camp with semi-permanent residents living under canvas and under the balcony of the outpatient department. Despite these limitations the outpatient department staff were ready and between 20 and 25 patients were seen in a somewhat abbreviated outpatient session at Dili Hospital. Most patients in this clinic came from within the Dili area itself and only a very small number of patients came from outside this region. The team had been assured that its visit was well advertised, but certainly a number of our local long term counterparts had not heard any notification over the radio or local television. At the completion of the outpatients the team took the opportunity to see a number of inpatients that the resident RACS general surgeon had requested review. A number of these were agreed to be placed on the surgical list to be done as combined procedures.
On Sunday morning those members of the team travelling to Baucau departed early to ensure arrival in time to commence an outpatient clinic later in the morning. Accommodation arrangements in Baucau were as in the past and there were no concerns with accommodation on this visit.
The outpatient clinic proceeded at the Baucau regional hospital during the late morning and early afternoon, with again between 20 and 25 patients being reviewed. A number of these had come from Viqueque in one bus. Unfortunately, a number of these cases had long standing musculoskeletal problems that were not plastic surgical in nature. Some will be reviewed by the upcoming orthopaedic team and others just need a general physician for review. There were however a number of cleft lip and palate patients presented including several from Viqueque. One of these was a 25 year old male with an unrepaired complete cleft lip and palate. Several patients came from Los Palos indicating that the message in this region had been better disseminated, although it is interesting to note that several patients from the Baucau and Lautem regions for whatever reason ended up going to Dili bypassing Baucau for treatment.
In both centres a number of patients with previously repaired cleft lips were reviewed and several of these were coming forward for subsequent repair of their cleft palates. Whilst some of these have had their lip surgery within the last 3 – 6 months and hence are coming back at an appropriate time, it remains disappointing that a number take many years to represent for their palate repair.
Surgery at Dili Hospital proceeded through the full 5 days. Dr Hayward combined with the resident anaesthetist, Dr Vreede, to perform as many surgical procedures as were possible given the limitations of the hospital and theatre complex at this time. The Baucau team returned on Thursday and it was possible on the Friday for both teams to work in parallel, allowing surgery to finish by about lunch time. Most surgical procedures were again either cleft lip and palate repairs or release of burn contractures.
The only patient in Dili which caused concern was the young infant with ulcerating lumbo-sacral meningomyelocele. This patient, already an inpatient in Dili Hospital being managed by the general surgeon, presented for surgery given the immediate threat to the child’s life by the incipient ulceration. Surgery proceeded largely uneventfully, but not unexpectedly, the patient became systemically unwell post operatively. With the combined management of all members of the team, together with the resident ICU staff the child was managed in the intensive Care Unit with high dosage antibiotics and by the time of the team’s departure was showing signs of improvement.
As noted previously several patients returned for palate repair in Dili and interestingly, one having had primary surgery in Baucau on the previous visit. The reason for the patient presenting in Dili was uncertain. Similarly one patient whom the team repaired the lip of almost 6 years ago eventually presented for palate repair on this occasion. A combination of poor communication and the patient often presenting late on previous visits meant that her eventual palate repair was much delayed.
In Baucau the predominant surgery undertaken was cleft lip and palate repair. These patients ranged in age from 5 months through to 25 years. The team was also asked to review a two year old inpatient with severe burns on all four limbs resulting in his already having had amputated his left leg above the knee. The burns on his remaining right leg were debrided and grafted. The ongoing management of his burns after the team’s departure will continue under Dr Phillip.
Whilst in Baucau the team was also able to see a number of long term cleft follow ups, some of these patients being seen in the market place where they recognised the team members. The team also had the opportunity to meet an old patient with previously treated fungal infection involving the face. It is now 2 years since she completed treatment and she remains disease free and well. This patient also assisted in bringing in a number of cleft patients to the clinic for assessment.
ORGANISATIONAL AND ADMINISTRATIVE ISSUES REQUIRING FURTHER COMMENT
1. Air travel to and from Timor Leste
The team, through its own contacts were able to make an arrangement with Air North for an excess baggage allowance. The details of this available on an email proved useful both on the team’s travel to Timor Leste but more particularly on departure from Timor Leste where bookings are not computerised. This allowed the team to travel without any excess baggage fees being paid.
The visa waiver documentation from the Ministry of Health also meant that the team entered Timor Leste without any immigration issues.
2. Accommodation and meals in Timor Leste
On this visit all accommodation was prebooked in Dili at the Hotel Turismo and in Baucau at the Hotel Pousada. There were no specific issues with either hotel on this occasion, although the Turismo has had a significant increase in rooms rate without an attendant increase in the quality of rooms or service. Alternative options in Dili may be worth exploring given the number of newer hotels around with comparable rates and better quality rooms.
3. Travel and transport
As on previous visits, vehicles were provided by the management of Rentlo for the cost of insurance only. This very significant support allows the team to be mobile whilst in Dili, but more particularly allows the Baucau based team to travel there easily and to provide service to those patients from the eastern end of Timor Leste. The team had the chance to meet briefly with the principal of Rentlo and provided him with copies of our report from the previous visit. They seem happy to provide support in this way and are willing to do the same in an ongoing fashion.
4. Hospital facilities /staff/ communication
a. RACS COORDINATOR
As noted above, all arrangements for accommodation were in place. The clinics were all prebooked for both Dili Hospital and Baucau Hospital. Unfortunately only about 20 patients turned up to each clinic at the allotted time. This was considerably less than what is normally seen in Dili and raises the issue as to how successfully notification of the visits is occurring to the regions. The use of local radio and television needs to be continued and the message received from a number of long term counterparts is that they did not hear the usual notification in those local media, although Mr Sarmento feels that this was done. The team hopes to go to Oecussi in the new year and this will similarly need to be well coordinated.
b.
OUTPATIENT CLINIC
The outpatient clinics were well staffed with the usual staff in Dili. The clinic in Baucau was once again held in the operating theatre environment. In Baucau the nurse anaesthetist staff were present and all patients were weighed and in both centres patients were assessed for any intercurrent disease such as to minimise the need for any subsequent deferral of treatment due to illness.
c. OPERATING THEATRE
Nurse anaesthetists: Those nurse anaesthetists in training and those who had already completed their courses were able to assist the anaesthetists in both locations. In Baucau the nurse anaesthetists in training undertook all intubations and was successful in all cleft patients on the first attempt. This reflects the high quality of training they are receiving.
Instrument nurses: Unfortunately, paralleling the above there are instrument nurses without any experience. In Dili Mr Francisco assisted the team extensively and his skills and expertise are of a very high level. In Baucau Mr Mateus has similar expertise, but is not always present with the team. It is in this area that something could be done with an expectation of a good return by running a similar instrument nurses course as that undertaken for the nurse anaesthetists.
d.
SURGICAL WARD POST OPERATIVE MANAGEMENT
In Dili the post operative surgical care leaves much to be desired. It has been commented upon on multiple occasions an is an institutional problem that will take a lot of time and effort to overcome. With the disruption to Dili Hospital it is difficult to make any headway with this problem. In Baucau the level of post operative ward care is also somewhat variable. Here the limitations are somewhat disguised by the dedication of Dr Phillip Mwaura.
e. MEDICAL STAFF
As on previous visits, the exposure to local surgical trainees is limited. Several are now overseas in training and Dr Joao Ximenes in Dili has commitments to general surgery. Dr Phillip in Baucau was again a major source of support. VISIT ASSESSMENT
STRENGTHS
· Continuing support from the Timor Leste Ministry of Health and RACS
· Regular, consistent provision of reconstructive surgical services which is not otherwise available in Timor Leste
· Ongoing contribution to the training of anaesthetic and instrument nurses in Dili and Baucau
WEAKNESSES
· Lack of exposure / opportunity to wok with local Timorese surgical trainees / students CLINICAL SUMMARY OCTOBER 19 – 27, 2007
Total Patient Consultations 73
Dili 39
Baucau 34
Total Surgical Procedures 40
Dili 23
Baucau 17
Cleft lip 15
Cleft palate 08
Burns 08
Other 09
SUMMARY OF TEAM ACTIVITIES OCTOBER 19 – 27, 2007.
October 19 Part of team depart Darwin to Dili Meet with ASSERT staff
October 20 Remaining team members arrive in Dili Consultation clinic at Hospital Nacional Guido Valadares, Dili
October 21 Part of team travel to Baucau Consultation clinic at Hospital Referral Baucau
October 22 Surgical procedures and consultations, Dili and Baucau
October 23 Surgical procedures and consultations, Dili and Baucau
October 24 Surgical procedures and consultations, Dili and Baucau
October 25 Surgical procedures and consultations, Dili and Baucau Baucau team departs to travel to Dili
October 26 Surgical procedures, Dili Dinner with Australian Ambassador, Dili
October 27 Team departs Dili for Darwin
ACKNOWLEDGEMENTS
· Timor Leste Ministry of Health, Royal Australasian College of Surgeons (RACS) and AusAID for their continued support of the team’s work in Timor Leste
· The resident RACS anaesthetist and team leader Dr Eric Vreede and Dr Phillip Mwaura, resident surgeon in Baucau.
· The staff of Rentlo Car Rentals in Dili who by providing a vehicle assisted the team greatly with its mobility in Timor Leste.
· Staff at ASSERT rehabilitation centre in Dili.
· The various Australian public and private hospitals and the surgical and pharmaceutical supply companies who continue to generously support our team’s work.
· Johnson and Johnson/Ethicon who continue to assist the team with specialist suture supplies.
· Tyco who have provided the team with surgical skin staples.
· To all the team members and their families whose support of this work in Timor Leste is greatly appreciated.
Mark H. Moore AM,
FRACS Team Leader
|
