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OVERSEAS SPECIALIST SURGICAL ASSOCIATION OF AUSTRALIA
TEAM VISIT
Cancar,
Flores
November 8 – 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
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, especially in the area of cleft lip and palate and burn and burn contracture management.
INTRODUCTION
Since 2002 the OSSAA Plastic & Reconstructive teams have had a central role in the expansion of the reconstructive surgical service available at the St Damian/St Rafael complex in Cancar, Flores.
From its initial establishment some 40 years ago this medical and surgical complex has prospered over the last 5 – 10 years in terms of the range of facilities available and the increased input of the OSSAA surgical teams across an increasing array of surgical specialties. Our surgical teams now visit regularly, providing a comprehensive reconstructive surgical service in concert with local counterpart medical, nursing and physiotherapy staff.
This visit in November 2008 is the second of this calendar year and follows on from a successful combined visit in June when the Plastic Surgical team visited both St Damian Hospital in Cancar and Rumah Sakit Marianum in Halilulik, West Timor. That visit represented the first attempt to expand our reconstructive surgical service more widely across the Nusa Tengarra Timur province and was seen to be a very successful innovation. On this occasion the team had arranged to meet with representatives from the St Elizabeth Hospital in Lela from the eastern end of the island of Flores as a preliminary step in negotiating a visit to this region in 2009, thus completing a 3 hospital facility providing coverage for reconstructive surgical complaints in the province of Nusa Tengarra Timur.
A two plastic surgical team was utilised on this occasion in Cancar and was accompanied for part of the week by Dr Harianto and his nurse/anaesthetist colleague. This was despite Dr Harianto having been recently unwell and the team not expecting him to be present on this occasion.
Coordination of the visit had been undertaken in the standard fashion between the team’s coordinator and local staff, resulting in the usual large number of patients presenting for assessment from broadly across Flores, but also the occasional patient still from West Timor and other patients from Sumba and Sumbawa.
TEAM MEMBERS:
Dr Mark Moore, AM Plastic Surgeon/Team Leader Dr Robert Coren Plastic Surgeon Dr Harianto Hendrikus Leprosy Specialist / Counterpart Surgeon Dr Philip Barnes Anaesthetist Dr Matthew Grill Anaesthetist Pak Wujiono Anaesthetic Nurse – Sitanala Ms Roslyn Sells Speech Pathologist Ms Amanda McFall Recovery Nurse Ms Vanessa Dittmar Operating Theatre Nurse Ms Ruth Boveington Coordinator / Interpreter
Counterparts:
St Damian St Rafael
Sr Elsa SSpS Sr. Franseline SSpS Dr Michael. Sr Maria SSpS Dr Irwin Pak Ferdi Jaleng St Daniella SSpS Pak Ferdi Jelalu Ibu Viktoria Nn Meri
Pak Kanis Nn Tanti Ibu Ernavati Pak Nasrin Ibu Sabina Pak Pontianus Kon Tamat Mas Dedi Tarung
LOCATION
St Damian and St Rafael Hospitals, Cancar, Kab. Manggarai, Flores, NTT
As noted above, the visits were coordinated and overseen by the SSpS sisters of St Damian and St Rafael Hospitals. The notification to patients of the impending clinic and visit was totally in their hands following communication from our team’s coordinator.
Following assessment the operating schedules for the week’s work were coordinated with the assistance of Ms Ruth Boveington and the local nursing and medical staff.
OVERVIEW
This OSSAA Plastic and Reconstructive Surgical visit was the second to Cancar in the calendar year 2008, continuing the frequency of visits that have occurred since early 2002.
With the regular, consistent nature of the team’s input, the local structure and organization are well tuned to the requirements associated with the team visits, culminating in yet another successful surgical mission.
The team on this occasion incorporated two Australian Plastic Surgeons who worked in concert with the local medical practitioners in Cancar, Dr Michael and Dr Irwin, both of whom have worked with our team on at least one occasion previously. Dr Harianto, out long term counterpart joined us from Jakarta, despite having been recently unwell and was accompanied on this occasion by Pak Wujiono a nurse/anaesthetist colleague from the Rumah Sakit Sitanala. The latter accompanied Dr Harianto to experience and observe the work undertaken by our team.
The team arrived in Cancar having been met at the airport in Labuanbajo by members of the St Damian Staff, who organised the road transfer. The travel from Bali was again courtesy of Indonesian Air Transport, this being organised by Mr Hendrik Tawur, who has very successfully organised the domestic air bookings in Indonesia for the team over the last year or two. Having arrived at St Damian late on Saturday afternoon, the team rapidly commenced assessment clinics, seeing some 20 or 30 patients before stopping for the evening.
The remainder of the clinic was undertaken through Sunday morning and into early Sunday afternoon. Of the 180 patients registered to come to the clinic, approximately 150 attended during the 24 hour period, allowing the construction of complete operating lists for two surgeons for the succeeding 5 days. A small number of minor cases were also set aside for Dr Harianto to perform local anaesthetic excisions during the 2 or 3 days that he was present with the team.
The members of the team, with the assistance of local staff were then able to set up the operating theatre complex on Sunday afternoon in anticipation of a full week’s operating.
As with all previous visits, the principal presenting complaint to the clinic were patients with cleft lip and palate. On this visit some 77 cleft cases were seen, most of these coming from the island of Flores, but with another couple of cases also from West Timor and also from the adjacent islands of Sumba and Sumbawa. Within this group were a number of patients on whom the team had previously undertaken lip repairs and were now coming back for repair of their cleft palates. There remain also a number of cases who are still unrepaired well into their teenage years, reflecting the lack of availability of reconstructive surgical services in this region of Indonesia. There are also a number of cases still being seen where repair has been undertaken elsewhere, the results of which are in need of significant revision.
With the number
of cases seen on this visit the team have now assessed something over 450
Amongst the cleft cases, 2 patients could be further defined as rare Tessier type clefts with extension of their clefting towards the eye sockets. The primary soft tissue repair of these cases was undertaken on this visit, one of these cases having been assessed on a previous visit.
In line with
the ongoing continuous cleft care being provided in this region, a small
The team was also accompanied by Ms Roslyn Sells, Speech Pathologist, who was able to undertake a pilot programme relating to feeding and speech in cleft lip and palate patients. Ms Sells has visited Cancar on one previous occasion and on this occasion her visit was part sponsored by the Adelaide Rotary Club and it is anticipated that the team will be able to provide an ongoing speech service aimed at teaching local staff the necessary skills to assist cleft patients in a basic fashion both from the viewpoint of feeding and speech exercises in relation to their repaired cleft.
As on previous
visits the other principal area requiring intensive surgical intervention is
the area of burns and burn contracture. A number of patients who have been
treated previously by the team presented for further release of contractures
and skin grafting on this visit. The excellent work undertaken by our local
counterpart physiotherapists has previously demonstrated that such work
produces excellent outcomes when combined with appropriate post operative
New burn contractures were also assessed and managed, including one lady with an extreme anterior neck burn contracture following a burn in February 2008. The aggressive burn scar contracture required wide excision of the burn scarring over the anterior neck and lower face, resurfacing this with extensive skin grafting. The post operative care will be managed by local staff who will maintain her in the appropriate neck splint once the grafts are stable.
A young 14 year old girl with similarly extensive burn contractures to the anterior neck and upper chest, seen on a previous visit, was represented for assessment. She had been hospitalised recently with a large fungating exophytic mass on the right upper chest in an area of old burn scarring. This had failed to heal despite an extensive course of antibiotics and dressings, this being overseen by Dr Michael. On this occasion the team opted to excise this area and resurface it with split skin graft. The neck burn contracture was left unattended until a subsequent visit. The tissue removed from this area was brought back to Australia for pathological review and was confirmed to be a squamous cell carcinoma arising in an old burn scar. This finding which is not uncommon after burn scars present for some 10 – 20 years, is somewhat unusual given that the burn in this 14 year old occurred only approximately 4 years ago. She will require further review when the team returns.
Another 5 year old was presented with an extensive burn over the chest and abdomen. The limitations of treatment for acute burns was noted in this case, given the complete absence of any form of dressing that would be available in Australia. Our hope is that on subsequent visits the team can take adequate supplies of Silver Sulfadiazine cream and ointment to assist in the management of such cases.
Other cases of note treated during the week included a number of advanced skin cancers on the face, as well as one patient with a rather large tumour arising from the right eyelid and extending into the right eye socket. The latter required orbital exenteration and histologically was demonstrated to be a malignant melanoma arising from the conjunctiva.
During the week the team was assisted by Dr Michael and Dr Irwin, the local medical practitioners servicing the St Rafael Hospital and Cancar community. Dr Michael will be there through until 2009 before returning to Java. At this stage it appears that Dr Irwin may also leave Cancar, albeit temporarily, to undertake surgical training in Bali. The intention is that he will then return to the region following this surgical training and be a very valuable and reliable ongoing counterpart for our visiting teams.
At week’s end the team reviewed all patients and was able to undertake a number of early dressings of patients. The follow up of cases will be undertaken by Sr Elsa, Dr Michael and Dr Irwin. Similarly the splinting and burn contracture management will be overseen by the physiotherapists at Cancar.
The team then travelled early on Saturday morning to Labuanbajo where it stayed in the SSpS long term rehabilitation facility at Binongko, just on the outskirts of Labuanbajo. Due to the flight arrangements for the team’s return the opportunity was available to allow the team to visit Rinca Island where the komodo dragons and macaque monkeys were seen.
On Sunday the team returned to Bali with onward transfer to Darwin and Adelaide on Monday.
During the week the team was joined by Sr Hironima, SSpS, the director of the St Elizabeth Hospital in Lela. This is an institution similar to that of Cancar under the auspices of the same order of nuns. She spent some 2 – 3 days with the team observing the work, participating and at a meeting agreement was made with her to undertake a visit to her institution during the period of 2009. This would allow patients from the eastern end of Flores to access the services of the OSSAA plastic and reconstructive surgical teams. The nature of the relationship that existed in Cancar was detailed to her so that she is fully appraised of the requirements of the counterparts and our teams in the local institutions.
STRENGTHS:
WEAKNESSES:
November 8, 2008. Team members assemble in Denpasar
November 9, 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 local staff and patient consultations commence.
November 10, 2008. Outpatient consultations Preparation of operating theatre
November 11, 2008. Operations, consultations, ward round, Dr Harianto arrives
November 12, 2008. Operations, consultations, ward round
November 13, 2008. Operations, consultations, ward round
November 14, 2008. Operations, consultations, ward round Farewell dinner with SSpS sisters.
November 15, 2008. Team departs Cancar for Labuanbajo to stay at Binongko. The team undertake a visit to Rinca Island.
November 16, 2008. Transfer from Labuanbajo to Denpasar with onward transfer to Darwin
SUMMARY OF
CLINICAL ACTIVITIES
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O S S A A
