OVERSEAS SPECIALIST SURGICAL ROYAL AUSTRALASIAN ASSOCIATION OF AUSTRALIA COLLEGE OF SURGEONS
TEAM VISIT
Cancar, Flores May 31 – June 07, 2008
Halilulik, West Timor June 07 – 12, 2008.
Naob, West Timor June 12 – 14, 2008.
TEAM LEADER’S REPORT
DR MARK MOORE AMMB, 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
With additional support from The Smile Train
AIMS AND GOALS
1. To maintain a regular, high standard, consistent Plastic & Reconstructive Surgical Service to those patients with physical disability and deformity, both congenital and acquired in the region of Nusa Tenggara Timur (NTT), Indonesia.
2. To work with the local medical and nursing staff in the hospitals visited to teach and transfer skills necessary for the management of patients with physical disability and deformity.
3. Expansion of the Plastic & Reconstructive Plastic Surgical Service from its long standing focus at St Damian Hospital, Cancar and develop a similar such facility at Halilulik and Naob, West Timor.
INTRODUCTION
The OSSAA Plastic & Reconstructive teams have played an integral part in expanding the surgical service available at the St Damian/St Rafael Hospital complex, Cancar, Flores. The initial leprosy clinic established some 40 years ago by Sr Virgula, SSpS has continuously evolved and in the last 5 to 10 years has expanded dramatically, allowing our teams to regularly visit and provide both high quality surgery and also to have an active role in teaching of local staff.
The focus at this institution has meant that patients from elsewhere in NTT, particularly those based in West Timor have had to travel extensively to avail themselves of this service. In a province where poverty is widespread this produces some hardship and OSSAA has sought to develop a similar facility in West Timor.
With the assistance of SSpS sisters, the PRR sisters and Dr Harianto new facilities and services are now available in Halilulik and Naob in West Timor. This team visit sought to not only continue its work in Cancar, but also to provide an aggressive expansion of the services available in the latter two centres.
The St Damian Hospital facility in Cancar has been utilised by OSSAA teams, and before that by our founder, Dr John Hargrave, since the early 1990’s. The facility now has 3 operating theatres and a well developed ward structure for the patients and has provided a first class facility for the provision of not only plastic surgical, but also orthopaedic and most recently, Ear, Nose and Throat surgical inputs by our teams.
The sisters running this facility have colleagues at a similar hospital complex in Halilulik, the Rumah Sakit Katolik Marianum which is now available to our teams to provide a similar such service. This was first utilised by our teams in 2007 when the first cleft lip and palate patients were treated in this hospital.
Paralleling this, Dr Harianto and the PRR sisters have been developing the leprosy and physical rehabilitation complex at Naob, located just outside of Kefamenanu. This facility in a more remote location has a simple operating theatre and ward block and at this time has a new operating theatre under construction which is almost complete.
The team sought on this visit to travel from Cancar and with a minor change in personnel, continue in the second week with a comparable workload at Halilulik and Naob. The team was accompanied and assisted throughout by Dr Harianto. At all locations local Indonesian medical practitioners and local nursing staff worked actively with the team, providing a service role as well as benefiting from the teaching services of the team.
Unfortunately on this occasion the Indonesian Association of Plastic Surgeons was not able to send a young plastic surgeon or trainee to accompany the team.
With the excellent communication between the team coordinator and local staff, travel between centres was easily organised and progressed efficiently, allowing for a high clinical workload to be undertaken. This represented a significant advance in the provision of service, particularly in West Timor, this taking some of the pressure off Cancar and also producing a significant cost saving for those patients and their support personnel who were not required to travel such great distances.
TEAM MEMBERS:
Dr Mark Moore, AM Plastic Surgeon/Team Leader Dr Harianto Hendrikus Leprosy Specialist / Counterpart Surgeon Dr Brian Spain. Anaesthetist (for Cancar) Dr David McLeod Anaesthetist (for Halilulik, Naob) Ms Penny Craig Theatre Nurse Ms Ruth Boveington Coordinator / Interpreter
Counterparts:
St Damian St Rafael RSK Marianum
Sr Elsa SSpS Dr Michael. Sr Helma SSpS Sr Maria SSpS Dr Irwin Sr Theodorine SSpS Pak Ferdi Jaleng St Daniella SSpS Sr Yosefa SSpS Nn Tanti Dr Tommy Sr Franseline SSpS Pak Pontianus Kon Tamat Ibu Ernavati Sr Raimundus SSpS Mas Ladis Ibu Sabina Grace Manek Mas Deny Pak Donny Wily Klaus Mas Timo Eder Milat
Naob PRR sisters
LOCATION
St Damian and St Rafael Hospitals, Cancar, Kab. Manggarai, Flores, NTT Rumah Sakit Katolik Marianum, Halilulik, Kab Belu, West Timor, NTT Naob Leprosy Hospital, Naob, Kab Timor Tengah Utara, West Timor, NTT
The visits at each location were coordinated and overseen by the respective order of nuns who ran the facility. The local organisation of patients and the timing of clinics and operating schedules had been planned with the assistance of Dr Harianto, Ms Ruth Boveington and the local nursing and medical staff.
    OVERVIEW
CANCAR
The OSSAA Plastic & Reconstructive surgical teams have made on average 2 clinical visits per year to Cancar since early 2002. With the frequency of visits, the local organisation is now well attuned to our visits and well know the organisational structure necessary to a successful surgical mission.
The team comprised a single Australian Plastic Surgeon, whilst Dr Harianto our long term counterpart, was able to assess and manage patients with some of the smaller and lesser surgical complaints.
The assessment clinic which commenced on Saturday evening soon after the team’s arrival was well structured and the patient selection and identification very appropriate to the surgical services provided by this team. A separate parallel clinic was undertaken by Dr Harianto to deal with the numerous patients with small lumps and bumps. Indeed with the number of these cases, known in Bahasa Indonesian has Benjolan (lump), Dr Harianto soon acquired the nickname of the ‘Benjolan Doctor’. During one day’s operating he undertook removal of such lumps from approximately 24 patients under local anaesthetic, not finishing his surgery until after eleven o’clock at night!
The team’s arrival in Cancar was remarkably uncomplicated. Travel from Bali to Labuanbajo occurred courtesy of Indonesian Air Transport. Mr Hendrik Tawur again ensured that the bookings were appropriately organised and personally came to the airport to deal with any excess baggage issues. The onward travel from Labuanbajo occurred on local buses. The weather on arrival was somewhat colder and wetter than expected, although this did improve during the week.
As stated above the assessment clinic started on Saturday evening and then continued through on Sunday allowing for the full planning of lists for the succeeding 5 days.
The operating theatre was set up on Sunday afternoon with the assistance of Ibu Sabina in the absence of Sr Reginaldis who is on leave.
The assessment clinic again turned up large numbers of patients with cleft lip and palate. A number of these were previous patients whose lip repairs have been completed and where the patients were returning for their cleft palate repair. A number of patients were seen who have had surgical treatment of their lips elsewhere in Indonesia, either by other visiting teams or by local surgeons. Unfortunately the quality of a number of these repairs is less than ideal and will require later revision of the cleft lip scarring. The team has now assessed almost 400 cleft lip and palate patients at Cancar since 2002 with some 377 surgical procedures being undertaken.
The other clinical condition of note which presents regularly remains patients with significant burn contractures. A number of these patients were those the team has treated previously and who were returning for further surgery. Of special interest was patient, Yanti, the young lady with both a bilateral cleft lip and neck burn contracture, treated on the previous visit, who had remained in Cancar in anticipation of further surgery. Whilst there had been a dramatic improvement in her appearance following her surgery in October 2007, the most impressive change was in her personality, with her now presenting as a much more confident and outgoing young lady, clearly much better adjusted than prior to initial treatment.
The team was assisted during the week by Dr Michael and Dr Irwin, the local general practitioners servicing the Cancar community and St Rafael Hospital. Whilst Dr Irwin was new to the team, Dr Michael had been present on previous visits and he actively assisted the team in surgery. Dr Michael has excellent surgical skills and should he consider a career in surgery, has the talents to perform well. Dr Irwin, who is a native of Cancar has returned there after medical school and it would appear has a long term commitment to the region and will be a valuable ongoing local counterpart for the team.
During the week the team observed the management of young man injured in a motor vehicle accident locally. Dr Michael was called upon to intubate and resuscitate the young man whose motor cycle had been struck by an oncoming bus. With major facial injuries he achieved the intubation of this patient under very trying conditions and our team aided him in the assessment and management of a major craniofacial fracture. Despite packing of both the mouth and nose, together with compression bandaging of the face, it was not possible to control the bleeding from within the head and neck area. This, in concert with a closed head injury, saw the young man die despite the use of all available clinical facilities. This incident did highlight the difficulties of managing extreme conditions in such a remote environment where support Xray and intensive care facilities are not available.
On the last day the team reviewed all the patients operated on during the week. There were many happy faces on the parents whose children’s clefts had been repaired. A number of the burn contracture releases will require ongoing dressings and this will be undertaken by local staff as they have in the past. Dr Michael and Dr Irwin will oversee in the longer term any issues regarding the surgical management of the burns prior to the teams return later in 2008.
Dr Brian Spain, Anaesthetist, then returned to Australia via Labuanbajo, whilst the remaining members of the team, including Dr Harianto, travelled via Ruteng onwards to Kupang to continue the second weeks work in Halilulik and Naob. Organisation of the travel from Cancar to Halilulik was facilitated by Dr Harianto and also Sr Teresia who confirmed the air travel. The flight from Ruteng to Kupang occurred with Intransit Ende. With arrival in the middle of the day in Kupang, it was possible for the team to visit the Merdeka Clinic where the SSpS sisters arranged lunch and a small clinic at which approximately a dozen patients were seen. From within this group of patients a small number were confirmed on the operating list in Halilulik and arrangements made for their travel to Halilulik.
The three members of the team who had arrived in Kupang from Cancar then travelled by car to Halilulik, whilst Dr Harianto waited in Kupang to accompany Dr David McLeod, Anaesthetist, who arrived for the second week on a flight from Bali.
HALILULIK – RSK MARIANUM
After arrival in Halilulik a clinic was undertaken in the evening. There were a large number of new cleft lip and palate patients requiring treatment and an operating list for the anticipated 4 days operating in Halilulik was quickly filled. A small number of other patients arrived on succeeding days.
The small existing operating theatre was set up for surgery. The theatre, whilst compact, was well provisioned and there were no specific issues in undertaking the large number of cleft patients. The hospital has almost completed the new operating theatre suite, incorporating 2 new theatres. This only needs the acceptance of the Provincial Health Minister and then these theatres will be available for use, ideally on the next visit.
On this occasion the spectrum of patients assessed were almost exclusively cleft lip and palate. The first cleft surgery undertaken in Halilulik was performed by Dr Bill Walker last year and this set the scene nicely for expansion of the service on this visit. With the absence of support services such as physiotherapy, occupational therapy and splinting it seems reasonable that the Halilulik set up should be used principally for the management of cleft lip and palate.
The team at one point undertook some 35 cleft lip and palate procedures sequentially and when a further 3 were performed in Naob, a total of some 38 clefts were repaired in a row! Surgery proceeded without event, other than one cleft palate patient who bled in the recovery area necessitating a return to theatre for control of bleeding from one of the palatal flaps. Following this the patient settled uneventfully and the local staff were well able to manage her in the post operative period.
By week’s end the patients were starting to be discharged from hospital and at that point there had been no issues of note during the post op care.
Once again Dr Harianto undertook removal of various lumps and bumps from a large number of patients. He was supported by Dr Melda, the local general practitioner present at the Rumah Sakit Katolik Marianum.
The team was accommodated within the larger SSpS complex in Halilulik, this being immediately adjacent the hospital, and provided a very comfortable home away from home. This was aided by Andy and Rachel Passey, VSO Management Consultant Volunteers present at Halilulik for one year to assist them in the development of their hospital. They welcomed the arrival of the team and provided excellent assistance to us during the week.
Dr Harianto organised for the team to travel to Naob on Thursday afternoon.    
NAOB LEPROSY HOSPITAL
The travel from Halilulik to Naob was organised by the PRR sisters and proceeded after completion of some 6 cases on Thursday. The 3 hour trip through the darkness saw us arrive in the remote area of Naob in the early evening. Welcomed by the PRR sisters the team was then able to undertake a short clinic that evening to identify those patients that could be operated upon on the Friday.
The anaesthetic machine was transported with the team to Naob, this having been organised by Dr Harianto.
Whilst Dr Harianto again saw a number of patients with soft tissue and skin tumours, the Plastic Surgical Team again saw principally clefts and some burn contracture patients. The latter included one young man, burnt some 4 years previously across the neck and left chest after explosion of a bamboo bomb.
On Friday the team undertook a further 5 cleft lip and palate repairs and 3 burn contracture releases including the above mentioned young man whose neck was released and skin grafted. The post op care again in this complex was very impressive and the physical expansion of the complex in the 2 years since the team leader visited Naob has been impressive. Once again there is a new operating theatre in an advanced stage of completion which should be available for use when the team next travels to this region.
On Saturday morning the team undertook its final ward round at Naob and then travelled by road to Kupang to connect with a Merpati airline flight to Denpasar. In Denpasar the team met up with the ENT team which had spent the last week in Cancar before travelling via airline back to Australia.
SUMMARY OF THE VISIT
STRENGTHS:
WEAKNESSES:
May 30 2008. Team members assemble in Denpasar
May 31, 2008. Team departs Denpasar on Indonesian Air Transport. Arrive Labuanbajo where met by Cancar staff and onward road travel to Cancar. Met in Cancar by Dr Harianto and patient consultations commence.
June 1, 2008. Outpatient consultations Preparation of operating theatre
June 2, 2008. Operations, consultations, ward round
June 3, 2008. Operations, consultations, ward round
June 4, 2008. Operations, consultations, ward round
June 5, 2008. Operations, consultations, ward round
June 6, 2008. Operations, consultations, ward round Farewell dinner with SSpS sisters.
June 7, 2008. Dr Brian Spain departs Cancar for Labuanbajo before onward flight to Denpasar. Remainder of team transfer to Ruteng for onward flight to Kupang. Three members of the team undertake consultation clinic at Merdeke clinic with SSpS sisters and then transfer to Halilulik for further outpatient consultations. Dr David McLeod arrives in Kupang from Denpasar before onward transfer to Halilulik.
June 8, 2008. Outpatient consultations and preparation of operating theatre. Two operations performed
June 9, 2008. Operations, consultations, ward round.
June 10, 2008. Operations, consultations, ward round.
June 11, 2008. Operations, consultations, ward round
June 12, 2008. Operations, consultations, ward round Team departs Halilulik for Naob where further outpatient consultations were undertaken
SUMMARY OF CLINICAL ACTIVITIES
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