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OVERSEAS SPECIALIST SURGICAL ROYAL AUSTRALASIAN ASSOCIATION OF AUSTRALIA COLLEGE OF SURGEONS
TEAM VISIT
TIMOR LESTE
MARCH 7 – 14,
2009.
TEAM LEADER’S REPORT
DR. MARK MOORE AM 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 volunteer surgical mission are as previously detailed:
1. The provision of a consistent, ongoing plastic and reconstructive surgical service to the people of Timor Leste, utilising personnel with the knowledge of and commitment to this region.
2. An active role in the teaching and training of our counterpart Timor Leste surgical, anaesthetic and nursing staff at the Hospital Nacional Guido Valadares, Dili and Hospital Referral Maliana.
3. The commencement of a basic training programme in cleft lip and palate surgery with an identified East Timorese counterpart surgeon.
INTRODUCTION:
Following a scoping mission to Timor Leste in December 2008, agreement was reached that this RACS/OSSAA Plastic and Reconstructive Surgical mission to Timor Leste should focus on both the Dili and Maliana regions.
This visit is the 25th clinical visit by this group since 2000 and is the 16th under the RACS administration and the 5th of the ATLASS project beginning in late 2006.
The objectives of this team were not only to introduce a plastic and reconstructive surgical service to Maliana for the first time, but also to expand the services in Dili. The latter will also incorporate discussions and the preliminary phase of a teaching programme in cleft lip and palate surgery for a previously identified Timorese surgical candidate.
Both the hospitals in Dili and Maliana are observed to be newly completed in December 2008 and there was enthusiasm from the staff in Maliana to commence the programme there, whilst in Dili Hospital the new operating theatre was now available for use by the team.
As a consequence of the improvement in facilities
available, this visit proved successful with more patients treated that have
been for some years.
TEAM PERSONNEL:
The visiting team was as follows:
Dr Mark Moore Plastic Surgeon/ Team Leader Dr Antonio Fernandes Plastic Surgeon Dr Peter Malcolm Anaesthetist Dr David Barker Anaesthetist Sr Josephine Luke Operating Theatre Nurse Sr Vanessa Dittmar Operating Theatre Nurse Ms Ruth Boveington Coordinator/interpreter
On this occasion all members of the team have had previous experience in working in Timor Leste.
Counterparts (all from Dili):
Dr Joao Ximenes Surgical Trainee Mr Manuel M.X Anaesthetic Technician Mr Eugenio Gusmao Anaesthetic Technician Mr Abilio Quintao Anaesthetic Technician Mr Fransisko Pinto Scrub Nurse Mr Carlos Quintao Scrub Nurse Ms Albertina M Scrub Nurse Mr Armando De Deus Scrub Nurse Mr Saturnina Belo Scrub Nurse Mr Fransisko de Araujo Recovery Nurse
OVERVIEW:
This latest visit by the OSSAA/RACS Plastic and Reconstructive Surgical Team to Timor Leste occurred as a follow up to a brief non-clinical visit to Timor Leste in December 2008.
At that time Dr Eric Vreede, coordinator of the programme in Timor Leste organised to meet Mr Mark Moore, Ms Penny Craig and Ms Ruth Boveington at the border with west Timor. These OSSAA team members were then able to visit the hospital in Maliana and in Suai and then return for discussions with the administration of the Dili National Hospital, as well as a representative of the Health Ministry. At the meeting agreement was had that the team would expand its clinical services to Maliana in 2009 and likely to Suai in the following years. In addition at that time, the proposition was raised by Dr Eric Vreede of the potential to train a young Timorese surgeon in the basic principals of surgery for cleft lip and palate. A preliminary programme was drawn up for this and this visit in March 2009 was to form the initial step of this programme, as well as providing the usual clinical input to those with plastic and reconstructive surgical problems in Timor Leste.
Discussions had also been had during this visit on the need to improve the referral and triage of patients for the visiting plastic surgical team to ensure not only appropriate numbers, but also those with an appropriate diagnosis are referred. To this end a poster detailing the treatment options available for cleft lip and palate has been constructed by Mr Elvis Guterres and the RACS office in Dili. This was in the process of being distributed to all regional centres and remote health posts to aid in referral.
The members of the team arrived in Dili principally from Darwin on the usual Air North flight. Two members of the team had in the previous week been working in Penang and arrived via the Silk Air flight from Singapore.
Those members of the team travelling to Maliana had vehicles provided by Rentlo and on the Saturday transferred to Maliana accompanied by a hospital vehicle.
The Maliana team, headed by Mr Tony Fernandes, then proceeded to assess patients on Monday and from within this group of patients were able to select patients for surgery on the following three days. This allowed successful implementation of our programme in Maliana without overstretching the hospital resources. These team members then returned to Dili on the Friday for return to Australia on the Saturday morning.
The Dili team commenced an outpatient session late on the Saturday afternoon when most patients were assessed. Because of some confusion between the various agencies involved in referring patients to Dili there continued to be patients arriving during the week, some of whom were able to be accommodated on the theatre list later in the week. As a consequence of this, approximately 80 patients were seen in Dili and more than 100 patients were assessed by the team in total.
The principal conditions that continue to be seen are cleft lip and palate, whilst there are also ongoing new cases with burns and burn contractures for assessment.
In regard to the cleft lip and palate patients, more than 40 were reviewed at this clinic, including a larger number of younger patients. With the present high birth rate in Timor Leste, there may be as many as 80 or 90 new cleft cases born each year and hence the team, with only 2 visits to Timor Leste per year will struggle to make inroads into this caseload, let alone dealing with large numbers of older untreated cases. The team after this visit has now undertaken more than 450 cleft lip and palate procedures in Timor Leste, whilst over 500 patients have been assessed since data collection commenced in 2000.
Surgery at Dili National Hospital proceeded uneventfully and with a large number of cleft patients being treated, the hospital authorities opted to open a ward specifically dedicated to the management of our cases. This had been done previously and the large open plan area proved very successful in allowing the preoperative and post operative patients to be appropriately managed and treated.
There were no specific complications associated with treatment, nor with their aftercare on this visit and all cleft patients were discharged within 2 days following surgery.
Of special interest amongst the cases treated was a 2 month old baby with a unilateral cleft lip and palate who had been previously seen by the Governor General of Australia, Quentin Bryce. This child, who bears the Governor General’s name, was referred for assessment. Fortunately the child, although only being 2 months old, was very healthy and with the presence of a specialist paediatric anaesthetist on the team we were able to proceed to repair the child’s incomplete cleft lip. This child’s post operative care as with all the other clefts was uneventful and they were able to return home soon after surgery
. Quentin Bryce
With regard to the teaching element of the visit, Dr Joao Ximenes has agreed to commence a programme of training in cleft lip and palate surgery and after discussions with him and Dr Eric Vreede, we anticipate this may take 2 – 3 years with active involvement of Dr Joao with our team during its visits, as well as the potential for him to accompany the team when they visit West Timor. Intermittent visits to Australia to understand the team based management of cleft lip and palate may also occur.
The team also had the opportunity to meet with staff from ASSERT regarding the number of patients with physical disability who would benefit from our team’s involvement and the coordination of this care with the physiotherapist and occupational therapists they can provide.
Our team had the opportunity on this occasion to work in the newly commissioned surgical theatres at Dili Hospital. The local anaesthetic nurses, as in the past proved to be of a very high quality and maintained a high interest and involvement with the team during the week. We were fortunate on this occasion to have local theatre staff actively involved and interested in scrubbing and working with the team. The team’s own theatre nurses were crucial in ensuring the turn over of instruments, allowing for more surgical procedures to occur on this occasion than have in past times. Without the turn over of equipment in this fashion, there would have been a considerable delays and frustrations.
ORGANISATIONAL AND ADMINISTRATIVE ISSUES
1. Air Travel to and From Timor Leste:
All air travel and issues in relation to excess baggage proceeded completely uneventfully. The new, larger planes being utilised by Air North relieved some of the issues regarding excess baggage on this occasion.
2. Accommodation and Meals in Timor Leste:
The hotel booking in both Dili and Maliana were well managed by Mr Sarmento. The team in Maliana enjoyed their accommodation and food provided in the small hotel which is located close to the hospital. The Turismo Hotel in Dili remains unchanged but is well liked by the team due to its proximity. At the hospital meals were provided on a regular basis to both the visiting team and local staff.
3. Travel and Transport:
Vehicles were provided to both the Dili and Maliana teams from Rentlo, this having been organised by Dr Eric Vreede.
4. Hospital Facilities/Staff Communication:
a. RACS Coordinator – on this occasion, as noted above, more patients turned up than in the past. This we believe was a consequence of the visit in December which revisited a number of the issues about communication from the past. There remained however some frustrations with perhaps too many people providing details in a relatively uncoordinated fashion such that confusion arose as to when patients should turn up in Dili and Maliana and the timing of such clinics. With refinements for following visits I anticipate this issue will be solved.
b. Outpatient Clinics – these proceeded uneventfully in both locations, albeit the timing of the clinics were somewhat at variance to that generally advertised.
c. Operating Theatre –
Nurse anaesthetists: these personnel made a very active contribution to the team and assisted the team’s anaesthetists in the delivery of high quality anaesthetics.
Instrument nurses: the instrument nurses in both locations made an active contribution to the team, particularly in Dili which was a great improvement on past visits.
d. Surgical Ward / Post Operative Management –
As noted above, in Dili this occurred in a ward which was dedicated to treatment of our patients. This once again proved highly successful and should be encouraged for all subsequent visits to Dili.
e. Medical Staff –
As has been detailed above, the team on this occasion commenced a training programme with Dr Joao Ximenes in cleft lip and palate surgery. For subsequent visits it is anticipated that an extra surgeon from our end will be sent so that whilst one surgeon undertakes the clinical side of things, teaching can occur in a second theatre with less pressure on the number of cases needing to be done. VISIT ASSESSMENT
Strengths:
· Maintenance of a regular, consistent plastic and reconstructive surgical service to Timor Leste
· Ongoing input into the training of anaesthetic and instrument nurses in Timor Leste
· Development of contacts and network in the Maliana region
· Commencement of a training programme in cleft lip and palate surgery with a Timorese surgical trainee
Weaknesses:
· On this occasion the only real weakness was in the overall coordination of visit with some confusion developing between the hospital staff, the RACS staff and other assorted NGO’s, including the Australian Army who were also disseminating information about the timing of clinics.
SUMMARY OF
CLINICAL ACTIVITIES
DILI
Total Consultations: 80
Total Surgical procedures: 34
Cleft lip/palate 29
Burns 02
Other 03
MALIANA
Total Consultations: 22
Total Surgical
Procedures: 14
Cleft lip/palate 08
Burns 04
Other 02 SUMMARY OF TEAM ACTIVITIES
Saturday March 7, 2009. Team departs Darwin and Penang for Dili. Maliana team travel to Maliana Consultation clinic at Dili Hospital.
Sunday March 8, 2009. Free day
Monday March 9, 2009. Surgical procedures and consultations Dili and Maliana
Tuesday March 10, 2009. Surgical procedures and consultations Dili and Maliana
Wednesday March 11, 2009. Surgical procedures and consultations Dili and Maliana
Thursday March 12, 2009. Surgical procedures and consultations Dili and Maliana
Friday March 13, 2009. Maliana team return to Dili Surgical procedures Dili Hospital
Saturday March 14, 2009. Team departs Dili for Darwin
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