OVERSEAS SPECIALIST SURGICAL ROYAL AUSTRALASIAN ASSOCIATION OF AUSTRALIA COLLEGE OF SURGEONS
TEAM VISIT – TIMOR LESTE
JUNE 29 – JULY 7, 2007
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 Referral Baucau.
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
The OSSAA/RACS Plastic and Reconstructive volunteer surgical mission to Timor Leste on this occasion is the twelfth visit performed as part of the AusAID sponsored and RACS administered Specialist Surgical project. The mission was the twenty first such undertaken by this team since early 2000.
The visit had been delayed from earlier in the year, and unfortunately coincided with Timor Leste parliamentary elections on June 30, with the attendant uncertainty perhaps limiting local travel and patients ease of transport to the hospital. The team was based in Baucau due to our having only a single surgeon team, and that other teams would be in Dili within a short period following our visit – hence to minimise disruption to normal routines at Hospital Nacional Guido Valadares.
Despite these constraints, the team was warmly received back in Baucau, where out last visit had occurred in May 2006. TEAM
PERSONNEL
The visiting team was as follows:
Dr Mark Moore Plastic Surgeon / Team Leader Dr Tim Semple Anaesthetist Sr Penny Craig Operating Theatre Nurse Ms Ruth Boveington Coordinator/interpreter
LOCATIONS AND COUNTERPARTS
Bairo Pite Clinic (Dili)
Dr Dan Murphy General Practitioner
Hospital Referral Baucau
Dr Phillip Mwaura Resident Surgeon Mr Antonio Correia Head, Operating Theatre Mr Alcino Anaesthetic Nurse Mr Anselmo Alves Anaesthetic Nurse Mr Mateus Instrument Nurse Mrs Carmina Instrument Nurse Mrs Regina Instrument Nurse Mrs Gina Instrument Nurse Mr John Instrument Nurse Mr Baptista Instrument Nurse
The coordination of the team’s visit was overseen by Dr Eric Vreede, resident RACS team leader and Mr Sarmento Correia. The latter accompanied the team to Baucau to assist with organisation of the visit, especially relating to the accommodation difficulties associated with the presence of so many electoral observers early in the week.
Despite the difficulties associated with the election, the team was pleased to have patients present, nor only from within the Baucau district, but also from the Lautem and Viqueque regions, which reflected on the dispersal of the message of the team’s presence.
The Baucau hospital, despite nor being well resourced, was well prepared for the team’s visit especially within the operating theatre setting. OVERVIEW
The team arrived on consecutive days – 29 and 30 June – this proved useful as there were significant limitations on airline baggage and risk of travel disruption over these days with the major influx of United Nations and other observers of the electoral process.
On Friday 29 June the team leader was able to be present to observe the ceremony to celebrate the sixth anniversary of the Hospital Nacional Guido Valadares where due recognition was given to staff whose dedication and commitment to the hospital has been long and unwaivering, especially through the troubles of 2006.
Later that day it was possible to briefly visit Dr Dan Murphy at the Bairo Pite Clinic in Dili. Several patients were assessed with the local health workers. Discussions with Dr Murphy identified that a young child with a presumed large facial haemangioma, assessed in November 2006, has displayed considerable resolution of symptoms and is no longer in need of consideration of treatment in Australia. Reprints of an article published in The Journal of Craniofacial Surgery (March 2007), which was authored by Dr Moore and Dr Murphy, on a long standing patient, were also left at the clinic.
The rest of the team arrived on Saturday 20 June, election day and proceeded to travel to Baucau. Having been ‘displaced’ from our accommodation for 2 days by various election officials the team settled in to the low budget ‘Casa Coures’ bed and breakfast.
The initial patient assessment clinic at the hospital was planned for Sunday commencing at 10 am. This allowed time for the team to briefly drive to Venilale prior to starting the clinic.
At the clinic, which was overseen by Dr Phillip and one of the local theatre staff, seventeen patients were seen, and operating lists prepared for the first 2 – 3 days. Time was available for the anaesthetist to re-acquaint himself with the theatre where he last worked in 2002.
With the disruptions caused by the election process, many patients arrived during the week so that by week’s end, 52 had been assessed. Most referrals were clinically appropriate reflecting the frequency and regularity of the team visits. Once again cleft lip and palate cases were the most common patients assessed. Of the 27 cleft cases seen, 21 were new referrals, bringing to a total of 489 cleft patients on our database since 2000. Of the 6 previously seen cases, 2 returned for routine post operative review and were noted to have good clinical outcomes. Three proceeded to cleft palate repair, two after lip repair by our team, and one after lip repair by a visiting German Interplast team in 2001 (this was a patient initially assessed by our team earlier in 2001).
Most of the new cleft cases were unilateral cleft lip without involvement of palate. Many cases had intercurrent chest infections, perhaps reflecting the general health status of many young children at the end of the wet season. This resulted in two cases being deferred due to being unfit for anaesthetic/surgery.
The operating theatre management of cleft lip and palate proved again to be uncomplicated – the theatre staff in Baucau being generally very efficient and professional. Whilst there were no specific post operative problems, the surgical ward staff did not generate a similar level of confidence, nor the cleanliness of the ward. It is recognised that a new hospital is to be built ands that little is being invested on upkeep of the existing structure. The support with post operative care from Dr Phillip Mwaura was as always highly valued. Unfortunately no East Timorese surgical trainee is present in Baucau, so teaching was afforded only to the local nursing staff.
Two significant burn contracture release procedures were performed. An adult with a dramatic ankle/foot contracture from a childhood burn should achieve a useful functional improvement. The other, a young epileptic child was less cooperative and despite release of her lower lip, elbow and hand, will likely have a lesser outcome and likely require more surgery when older.
Several patients with large head and neck masses also presented. A two and a half year old child with a large superficial, encapsulated tumour over the parotid underwent complete excision of what appeared to be a lipoma-like tumour. A middle aged woman presented on the last day with a similarly impressive parotid mass and was assessed for surgery on a subsequent visit.
The final morning in Baucau also saw the opportunity to review a young child with a leg/ankle contracture caused by a green snake bite which we treated with a buttock to heel pedicled flap 18 months ago. He has a fully functional leg and is able to run normally.
Organisational and administrative issues requiring further comment include:
1. Air travel to and from Timor Leste
Air travel difficulties related principally to the timing of this visit during the week of the elections. Flight and baggage restrictions in place at this time meant the team was threatened with delays of its baggage – this only occurred on the return flight so did not disrupt our clinical activities. Excess baggage was charged by Air North in both directions despite this team travelling considerably lighter than many other teams.
The document for waiver of the entrance visa fee was readily accepted.
2. Accommodation and meals in Timor Leste
Changes to our usual accommodation were required due to the large number of electoral observers. Their ‘louder’ voices meant we were shifted from the Hotel Pousada and Hotel Lorosae in Baucau, spending two nights in Casa Coures, a small bed and breakfast facility which is as yet unfinished and not suitable for long term occupancy. The remainder of the visit we were relocated to the Hotel Pousada, which was a major step up.
Meals were regularly available at the two – three restaurants in Baucau, with fresh fruit etc from the local markets.
3. Travel and transport
A 4-WD vehicle was again provided by the management of Rentlo at the cost of the insurance only. This support of our team allows for these ongoing outreach clinics in more distant districts at a considerable saving in cost, and is much appreciated.
4. Hospital facilities / staff / communication
a. RACS Coordinator
Under the difficult circumstances and timing of this visit Mr Sarmento was able to facilitate a successful visit. Patients from Lautem and Viqueque confirmed the notification of our visit had been widespread with sufficient cases to fully occupy the team during the week. His accompanying the team to Baucau also assisted in sorting out the accommodation difficulties.
With the planned visit for October 2007 we envisage a two surgeon/location team and the final decision on that will be made soon – likely Dili and Baucau with perhaps Oecussi in 2008.
b. Outpatient Clinic
There were no difficulties with the preoperative assessment clinic. The Baucau theatre staff and Dr Phillip Mwaura are well aware of the team’s routine and facilitated the clinical assessment and admission process. The two cases deferred because of illness were identified as unwell in the clinic and admitted early for antibiotic treatment, unfortunately to no avail.
c. Operating Theatre
Nurse anaesthetists: The three nurse anaesthetists in Baucau have completed the RACS course and worked with our team on many occasions. Their interaction with the team anaesthetist, Dr Semple was highly valued on both sides.
Instrument nurses: While several of the more senior nurses have moved on, often to the nurse anaesthetist programme, there remain a good core of skilled instrument nurses, with a number of new staff who are enthusiastic and willing to work.
The leadership provided by Mr Antonio and Dr Phillip always ensures that Baucau theatre is a pleasure to work in.
d. Surgical Ward Post Operative Management
As noted above, the surgical ward nursing care leaves much to be desired. The nurses often do not seem to be aware of where patients are, and any semblance of coordinated care overseen by the nursing staff seems minimal. Despite regular ward rounds by our team at the beginning and end of the day, few were accompanied by local staff and most communication occurred directly to patients and their families – the latter being responsible for most of the patient care. Several better trained nurses seem to have left the ward and moved to the operating theatre, perhaps as a promotion.
Intravenous fluids were readily available, although other drugs were in short supply. The team left a supply of oral Paracetamol with the hospital.
e. Medical Staff
The team had little direct interaction with the local medical staff on this visit. Dr Phillip, the resident Baucau surgeon, as he has previously, worked closely with the team. He was able to utilise our team anaesthetist for a one month old infant with an anorectal agenesis and fistula development – this very unwell baby had a successful surgical intervention and by week’s end was prospering.
The team leader met briefly with the Health Minister, Dr Rui Araujo and with Dr Joao Pedro the Timor leste trainee during the HNGU celebrations.
VISIT ASSESSMENT
Strengths
Weaknesses
CLINICAL SUMMARY JUNE 29 – JULY 7, 2007.
Total Patient
Consultations 52
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Monday 02-07-07 |
Tuesday 03-07-07 |
Wednesday 04-07-07 |
Thursday 5/07/07 |
Friday 06/07/07 |
|
1. Narnia Corrie Costa Freitas, Repair ® cleft lip |
Anito Da Silva, m, 1/12 SSG scalp |
Eldinita Franscesca Costa Cabral, Repair left cleft lip
|
Febrian Sarmento, 1y 3mo. ® Cleft lip repair |
|
|
2. Tito Correia, 2y. Cleft palate repair |
Sariana Sarmento, 5y Release lip/hand/elbow contracture
|
Ivonia Soares, release leg burn contracture |
Juvencio Da Cruz, 1y 7mo Repair bilat cleft lip |
|
|
3. Josephina da Costa Lopes, Repair left cleft lip |
Abreia Soares Freitas Repair left cleft lip
|
Ana Maria Dominges, 1y 7mo. ® cleft lip repair
|
Abitu Belo, m, 1y 6mo Right incomp cleft lip repair. |
|
|
4. Cornelia Dos Santo, 5y. Repair cleft lip |
Natalicia Belo, 12y Repair cleft palate |
Maria Madaleina, 2y Repair right cleft lip |
Dominggas Das Dores Buavinda 7yr Cleft palate repair |
|
|
5. Nielania Amaral, 3y Repair left incomp cleft lip |
Estefania Fernandes Exc malformation right hand |
Paulo Noni Marques, 5y Isolated cleft palate |
Esperancia da Costa, 7y Repair left cleft lip. |
|
|
6. Dominggus Guteres, keloid ® ear, Exc + kenacort L/A |
Rinto Pereira, 17 y Exc keloid left ear / kenacort L/A |
Dewi Freitas, 2.5 y Exc mass ® cheek |
Adozinda dos Santos, 17y Cleft lip repair |
|
|
7. |
|
Sejinha Maria, 16y Exc cyst eyebrow |
Marselo Ximenes Cleft lip |
|
....................................................................................................................................................................................................................
Overseas Specialist Surgical Association of Australia
Program: Plastic Surgical Team Hospital: Baucau Regional Hospital Date: 29/06 - 06/07, 2007
|
No |
Name |
Age |
Address |
Clinical Notes/Plan
|
Surgical Notes/Follow up |
|
|
M |
F |
|||||
|
1 |
Filomena |
|
3/52 |
HNGU |
? myclomeningocoele – aborted. Local - General surgeon to excise. |
|
|
2 |
Carlos de Jesus |
31 |
|
Bebonuk |
Cyst ® ear. L/A |
|
|
3 |
Lusia Faria |
|
30 |
Bairopite |
Scar ® Upper lip. W/L |
|
|
4 |
Pedro |
4 |
|
Bairopite |
Leg wound ? TB – chronic. / traumatic |
|
|
5 |
Fernandes |
12 |
|
Bairopite |
Pressure ulcer back. Now healing |
|
|
|
BAUCAU |
|
|
|
|
|
|
6 |
Tomasina Ximenes |
|
7 |
Kota Baru |
Left cleft clip – old patient Scar good – needs work on speech. |
|
|
7 |
Dominnggus Guteres |
41 |
|
Baucau |
Keloid ® ear. L/A exc + kenacort. |
2/07/07: Excision keloid ® ear, kenacort. 6-0 Nylon Surgeon: M Moore L/A |
|
8 |
Tito Correia |
2.5 |
|
|
Previous cleft lip repair (9/05). Good scar. For cleft palate repair |
2/07/07: Repair cleft palate. 2 – flap, Intravelar veloplasty. 4-0 Vicryl Surgeon: M Moore Anaesthetist: Tim / Alcino |
|
9 |
Hermenegilda Belo |
|
24 |
Bidau |
Large vasc. Malformation floor of mouth / tongue. Review 1year in Dili when ICU better developed. |
|