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Team Visit - West Timor June 28 - July 9 2006
Team Leaders Report
Dr Peter Riddell MBBS FRACS (General Surgery) (Plastic and Reconstructive Surgery)
Funded by OSSAA
OSSAA VISIT REPORT June 2006
PROGRAMME NAME: OSSAA Rehabilitation, Surgical and Training Programme
LOCATION: RSU Kefamenanu, West Timor
DATE OF SURGICAL VISIT Commencement Date Wednesday 28th June 2006 Completion Date Sunday 9th July 2006
TEAM MEMBERS P. Riddell Surgeon, Team Leader B. Miller Surgeon F. Merritt Anaesthetist J. Reynolds Anaesthetist S. Wager Theatre Sister K.Coombe Theatre Sister A. Kartika Coordinator/Interpreter
The team was accompanied by G. Marshman Dermatologist E. Darmaji Indonesian Medical Practitioner
IMPLEMENTING ORGANISATIONS
Dinas Kesehatan, NTT RSU Kefamenanu, West Timor RSU Prof Johannes, Kupang RSU Atambua, West Timor SSPS Sisters RVM Sisters PRR Sisters, Naob
Participating Individuals Bupati Kefamenanu: Bapak G. Manek Kepala RSU Kefamenanu: Dr Hartono Sister Yasinta, RVM
Medical Staff RSU Kefamenanu
Dr Nining Dr Lely Pangaribuan
Nursing Staff RSU Kefamenanu Sister Alvira Bani
FUNDING SOURCES
OSSAA: Travel, accommodation and in transit expenses Volunteer days - 96
Local contribution (Kabupaten TTU) Team accommodation Team transport Team meals Team hosting Team interpreting
Other contributions Medical consumables: Dynek (sutures), J&J (sutures and $2000 donation) OPAL (pharmaceuticals) Olympus (Sharon Fuller) Welch Allyn (Jane Archibald)
AIMS AND GOALS
GOALS
1. To undertake formal training in the management of surgical patients to all staff at Kefamenanu Hospital 2. To work co-operatively with hospital and health staff in undertaking surgery in the provincial town of Kefamenanu, West Timor 3. To further extend and develop the patient referral network previously established when working in West Timor during 19995-19999, and more recently 2003 - 2006
SPECIFIC AIMS
· To continue to continue the regular surgical visiting programme to RSU Kefamenanu, providing access for the people of the district to surgical services in general/reconstructive surgery.
· To assist the development of referral services at RSU Kefamenanu
· To assist in the development of other services at RSU Kefamenanu; on this visit, specialist dermatology services.
This was the second visit to the hospital for 2006.
DETAILS OF VISITING PROGRAMME
Itinerary This was the second visit to West Timor for 2006, and followed a highly successful visit in March/April. It was the first visit for Jeni Reynolds, Gill Marshman Kath Coombe and Elly Darmaji Team members met in Sydney on Wednesday 28th June to fly to Denpasar. The flight was uneventful, as was clearing customs in Denpasar, thanks to the preceding organisation of Arto Kartika and Dr Elly Darmaji, who met us at the airport. Unfortunately Qantas had left one personal suitcase in Sydney, which was eventually delivered to Kupang later in the visit. The evening was spent at Udayana Lodge, and included a final briefing session about the forthcoming work. The following day the team flew to Kupang and were taken to Prof Johannes Hospital. A ward round with the local (and at the time, the only) general surgeon (Dr Mateus) showed some of the difficult surgical cases presenting to this referral hospital. On Friday 30th June, the team was hosted to a morning seminar at the Prof Johannes Hospital focussed on future co-operation with OSSAA . This was followed by a meeting with the Governor of NTT, Bapak Piet Tallo, who thanked the team for their ongoing support in West Timor, and discussed further collaboration with OSSAA. The majority of the team drove to Kefamenanu that afternoon and undertook consultations, for surgery to commence the following day. Peter Riddell and Jeni Reynolds stayed in Kupang. They had been requested to work co-operatively with Dr Mateus at an operating list. This proved very successful. Dr Elly Darmaji and Gill Marshman in the meantime also had had a very successful afternoon consulting with Dr Nyoman Sutama, the sole dermatology consultant in NTT. The Saturday was spent operating in Kefamenanu. The Kupang members arrived at lunchtime, with both teams operating for the rest of the day. Sunday as usual was a rest day, and was spent on a day visit to Naob, the leprosy clinic in the rural district. Gill Marshman had an opportunity to discuss the leprosy patients with Dr Hari who was working there. The team members were also able to review patients operated on previous visits. Monday, Tuesday and Wednesday were busy with the two teams operating at RSU Kefamenanu. The usual mix of general and reconstructive surgery kept all busy. The team received a call from the Director and the resident general surgeon at Atambua Hospital, for assistance in treating a septic patient. Consequently Peter Riddell, Jeni Reynolds and Sue Wager travelled to Atambua on Wednesday night and successfully operated there on Thursday with the surgeon (Dr Wayan). There was a large practical teaching component to the visit. They met Dr Elly Darmaji and Gill Marshman who had arrived there previously and had been consulting there. The team members returned to Kefamenanu that evening after a long day. The other team had continued to operate there in the meantime. Friday was the final full operating day for both teams at Kefamenanu and was busy. The team had an early start on Saturday morning, travelling to Kupang, then flying to Denpasar, before flying to Sydney that night. All arrived weary in Sydney on Sunday morning after a very successful and enjoyable trip.
Clinical Consultations The usual wide variety of surgical patient presented to the teams, many with advanced pathology, the majority amenable to surgery, but some beyond surgical help. Patients were waitlisted for future consultation. The well organised consultation and triage system within the Kefamenanu hospital was impressive, and had improved even beyond the previous visit.
Operations The teams were involved in a wide variety of operations, both elective and emergency. Examples of the former included hysterectomy, bladder stone removal, hernia, eye tumour extirpation, major head and neck surgery, treatment of acute burns and chronic burn contractures, musculoskeletal surgery and breast, thyroid, abdominal and paediatric surgery.
Training for counterparts The ongoing training for the theatre and ward nursing staff continued. Sue Wager is particularly to be commended for her theatre sister training, which in combination with Sue Davis, has now trained a very competent theatre staff. Dr Nining is now undertaking many operations herself, learnt from repeated OSSAA visits. The two unscheduled visits to Kupang and Atambua both encompassed a large amount of time in teaching/skills transfer.
Equipment The surgical equipment at RSU Kefamenanu is currently of adequate standard. The state of the anaesthetic equipment is outlined in the separate anaesthetic report. Brian Miller brought, and has left, a bronchoscope and gastroscope to Kefamenanu kindly donated by Olympus courtesy of Sharon Fuller
Enhancing medical services at Kefamenanu Hospital The concurrent dermatological visit by Dr Gillian Marshman and Dr Elly Darmaji was of great assistance to the RSU Kefamenanu and the OSSAA team. There is considerable overlap in diagnosis of surgically presenting systemic disease and its cutaneous manifestations. Having consultant dermatological expertise was invaluable in many cases presenting to the teams. There is likely to be further advantage to the West Timor community through this visit.
ANAESTHETIC REPORT Dr Fiona Merritt already submitted
NURSING REPORT - Sister Sue Wager This latest trip has been one of reflecting and feeling proud of just how far we have come with Kefamenanu hospital. We started off at the beginning with a hand full of nurses, who were very keen. Now with two teams we obviously need more theatre nurses and they have been coming from all over the hospital to join the team and learn either theatre or anaesthetic skills. I even witnessed one of the more experienced staff there teaching a new member on how to hand the instruments to the surgeons. So the teaching continues. I found it wonderful to see nurses automatically wearing gloves when handling blood products (something they did not do when we first arrived there). With our teaching, they now understand about blood borne diseases and the concept of transferring this by hand and the importance of washing everything. This is just one small example of many things they have learnt. It has been great seeing all the same faces and meeting more. I am sure they are happy also to see our familiar faces and meeting a couple of new ones as well. On the previous trip to Kefamenanu in April this year, Kerrie Nicholls, an experienced theatre nurse from Newcastle came along. And this latest trip I introduced another experienced theatre nurse from flinders medical centre, Cath Coombe. Both girls got on well with our team members and staff at Kefamenanu and fitted in really well. They are both keen to go back on other trips again. And hopefully they may be able to introduce others. They mentioned that it was great to go with someone who has been before as a hand over effect. I think it is good also to have this so there is continuity for the staff over there and standardised procedures. All our equipment and consumables are now well organised. The hospital has acquired cupboards and benches so we do not need to work out of cardboard boxes any more. They are really trying hard to accommodate anything we need. It shows they are in this for the long ride. One of the nurses even organised toilet paper hanging in the toilet for us. This may seem very trivial to those who have not experienced a culture where they do not use toilet paper. But to us it was wonderful. I was fortunate to make the journey to Atambua for a day of operating, and it made me realize just how far we have come at Kefamenanu hospital. At a conference in Kupang Hospital, we also found out that they are ‘jealous’ of Kefamenanu Hospital. This is because they feel they need help also. We had a tour of their hospital and theatre suite, and realised they were considerably lacking as well. The anaesthetist had very limited equipment, so we donated boxes, containing intubating tubes and masks. It was a new experience having a dermatologist with us for some of our trip. I had not really thought about how much dermatology and plastic surgery go together. I learnt a lot about many tropical diseases. Gill Marshman and her lovely interpreter Dr Elly Darmaji (who met us in Bali airport and got us through customs) were a great part of our “team”, even though they were self-funded. They were able to consult with many dermatology patients and refer to the surgical team those who needed surgery. It saved the surgeons a lot of time, allowing them to see other patients. It is like one big family every time we go over and lovely to see the same faces. All our team got on very well and are all keen to go again. I myself am in need of a break as it takes so much time from my family and income. I have been October last year. March/April this year and now again June/July. I feel very happy with the work we have achieved, and that Kefamenanu hospital is set up ready to go and that we have a great team of nurses to continue the teaching.
Sue Wager Registered nurse FMC.
CO-ORDINATOR REPORT Pending
WORKLOAD SUMMARY KEFAMENANU, TTU - NTT
GENERAL CONSULTATIONS
COMBINED SURGICAL/DERMATOLOGY CONSULTATIONS
DERMATOLOGICAL CONSULTATIONS
TOTAL SURGICAL PROCEDURES 61 Plastic/Reconstructive 10 Head and Neck 6 Hernia 19 Orthopaedic 0 Abdominal 7 Urology 7 Gynaecology/Obstetrics 7 Breast 5
TEAM MEMBERS Dr PETER RIDDELL Surgeon Dr BRIAN MILLER Surgeon Dr FIONA MERRITT Anaesthetist Dr JENIFER REYNOLDS Anaesthetist Ms SUZANNE WAGER Theatre sister Dr ARTO KARTIKA Co-ordinator Interpreter M KATHERINE COOMBE Theatre sister Dr ELLY DARMAJI Indonesian Medical Practitioner Dr GILLIAN MARSHMAN Dermatologist
COUNTERPARTS Dr NINING Doctor (GP) Dr LELY PANGARIBUAN Doctor (GP) Mr SIMON SERAN Nurse-in-charge OT Mr ANTONIUS SALU Anaesthetic nurse Mr PETRUS MEOL Anaesthetic nurse Mr COSMAS ELU Anaesthetic nurse Mr MUNDUS OKI Anaesthetic nurse Mr GENIETRIX HON Theatre nurse Ms FIFY MARIA G. SANI Theatre nurse Ms IMELDA BRIA Theatre nurse Ms ELDA MARIA T. Theatre nurse Ms ALVIRA BANI Nurse-in-charge consulting clinics Ms MAGDALENA UN Nurse-in-charge sterilisation Mr STEPHANUS SOY Cleaning service Sr YACINTA HOARE RVM Interpreter/facilitator/ pastoral care
Administrative and Personnel Arrangements Local infrastructure was excellent, with the continued extraordinary assistance to accommodate the team's needs by the Kefamenanu hospital/NTT Department of Health. All team members performed in an outstanding capacity. This was the first visit for Dr Jeni Reynolds, Sister Cath Coombe and Dr Gillian Marshman. All did an excellent job, and are to be thanked sincerely for their efforts. The other team members have again volunteered their time and services to come to Kefamenanu. This was the second visit for Dr Fiona Merritt, and Dr Arto Kartika, with the others having now had multiple visits. OSSAA remains pivotal in maintaining this ongoing surgical and reconstructive programme, with thanks especially to Mr Bob Laws (President of OSSAA) and Mrs Sue Freeman (Secretary of OSSAA) for their leadership and administrative skills.
DISCUSSIONS WITH LOCAL COUNTERPARTS
Points raised by counterparts To continue the current programme with the same personnel and format, based on a surgery-in-general approach, with expansion, through further visits, of the programme to Kupang and Atambua.
Repeated request to continue the dedicated formal teaching of staff.
Repeated request for ongoing regular support by current Australian personnel with 2 teams on each visit to Kefamenanu.
Forward plans for one further visit to Kefamenanu for 2006.
ACKNOWLEDGEMENTS Bapak Piet Tallo Governor NTT Dinas Kesehatan NTT Bapak G. Manek Bupati TTU Dr Hartono Dr Nining Sr Yasinta RVM All OSSAA team members and their families OSSAA committee for their ongoing support
SUMMARY A very successful visit to RSU Kefamenanu, with visits to hospitals in Kupang and Atambua.
The team remains highly committed to skills transfer through teaching and long term collaboration. This visit continued to realise that aim.
Dr Fiona Merritt's observation that she was needed in a supervisory capacity only, and was not the primary anaesthetist in one case on this visit, is a good example of OSSAA's cumulative achievements in skills transfer at RSU Kefamenanu. INDIVIDUAL CASE PRESENTATIONS/PHOTOGRAPHS
OSSAA and dermatological team Prof Johannes Hospital, Kupang
Governor of NTT (Bapak Piet Tallo) with members of the OSSAA and dermatological team
PRE - OPERATIVE VIEW
A four year old child with a right eye tumour which had been present for an uncertain length of time, which was treated by the team by eye enucleation.
POST - OPERATIVE VIEW
Dr Fiona Merritt supervising anaesthetic
nurse Petrus Meol in spinal anaesthesia
Dr Brian Miller with Dr Arto Kartika examining a patient with goitre. A study is being undertaken to look at feasible medical management of this common condition in Kefamenanu.
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