OVERSEAS SPECIALIST SURGICAL ROYAL AUSTRALASIAN ASSOCIATION OF AUSTRALIA COLLEGE OF SURGEONS
AUSTRALIA TIMOR LESTE PROGRAMME OF ASSISTANCE SPECIALIST SERVICES (ATLASS)
TEAM VISIT – TIMOR LESTE
JULY 5 – 12, 2008.
TEAM LEADER’S REPORT
DR. MARK MOORE AM MB,ChB, FRACS PLASTIC AND CRANIOFACIAL SURGEON
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 specified:
1. Providing a regular, ongoing plastic and reconstructive surgical clinical service to the people of Timor Leste, utilising personnel with a 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 Referencia Baucau.
This single surgeon RACS/OSSAA Plastic and Reconstructive volunteer surgical mission to Timor Leste is the 23rd such visit by this group since it began regular input in this region in 2000. It is the 14th under the RACS administration and the 3rd of the ATLASS project beginning in late 2006.
Whilst the general situation in Timor Leste has been stable for some time, the situation at the national hospital in Dili remains somewhat unsettled, with ongoing ward reconstruction, the new operating suites not yet commissioned and limited availability of sterilising / autoclaving facilities. The team’s activities therefore focussed again in the eastern districts with surgery and clinics in Baucau and the reactivation of an assessment clinic in Los Palos
Immediately prior to departure to Timor Leste the team was unofficially informed of a planned US Mercy ship visit to Dili, including cleft lip and palate surgical services courtesy of Operation Smile Australia in the week following our visit. Arrangements surrounding this particular activity may have impacted on the activity level of our team during the week, and highlights issues surrounding the in-country notification of impending specialist surgical team visits.
Despite these issues, the activities of the team on this visit exceeded what has been possible previously. TEAM PERSONNEL:
The visiting team was as follows:
Dr Mark Moore Plastic Surgeon/ Team Leader
Dr Tony Pearce Anaesthetist
Sr Vanessa Dittmar Operating Theatre Nurse
Ms Ruth Boveington Coordinator/interpreter
For both the anaesthetist and theatre nurse this was their first visit to Timor Leste although both have worked elsewhere in the Indonesian archipelago.
Counterparts:
Dr Phillip Mwaura Surgeon Baucau Mr Antonio Correia Nurse in Charge OT Baucau Mr Alcino Nurse anaesthetist Baucau Mr Anselmo Alves Nurse anaesthetist Baucau Mr Valerio Nurse anaesthetist Baucau Mr Fransisko Nurse anaesthetist Baucau Mr Mateus Instrument nurse Baucau Mr John Instrument nurse Baucau Mr Batista Instrument nurse Baucau Mrs Regina Instrument nurse Baucau Mrs Tina Instrument nurse Baucau
Mr Bernardo Amaral Lopes Nurse in charge clinic Los Palos Mr Amadouru Samepalo Nurse Los Palos Mr Faustino dos Santos Nurse Los Palos
Dr Dan Murphy General Practitioner Dili Bairo Pite Clinic
OVERVIEW:
The four members of this team arrived together in Dili early on Saturday 5 July. After collecting a vehicle as arranged from Rentlo, the team travelled to Baucau with our supplies transported separately in a Baucau Hospital car. Prebooked accommodation in Baucau was secured and the team presented to the theatre at the hospital for the planned outpatient assessment clinic.
The clinic was organised and directed by Dr Phillip, Mr Anselmo (nurse anaesthetist) and Sarmento (RACS coordinator). Despite assurances of wide public advertisement of this clinic only 12 patients were presented! Apart from two brothers with cleft lip and palate that Mr Sarmento personally organised to come to the clinic, the remaining cases were triaged and referred by Dr Phillip.
Among the cases presented included a 3 year old boy with severe burns involving all four limbs whose unhealed right leg burns were grafted o the last visit. On this occasion we were able to release the severe flexion contracture of the left wrist and hand with skin grafting. His opposite hand and wrist will require treatment on a future visit.
Another teenage girl whose arm burn was released from her chest on a prior visit, on this visit had further release of her axilla and elbow region, allowing a full range of movement in this limb.
A 3 year old with a large, benign, parotid tumour excised one year ago presented with local recurrence more extensive the primary lesion, still without facial nerve involvement. Surgical excision, apparently complete was possible again with specimens brought to Australia for pathological review and options for further treatment.
No patients at the clinic in Baucau came from Venilale or beyond in the Viqueque district, raising the issue of the adequacy of the visit notification. The team was also informally notified of a health ministry request to ‘hold over’ cleft lip and palate cases for the US Mercy ship visit to Dili a week or two after our visit. If this is correct, it questions the logic motives and capabilities of those in the health ministry who would have patients travel 4 – 6 hours to Dili, bypassing Baucau and a known surgical team providing regular, ongoing care to have treatment by an unknown service and no established long term clinical follow up mechanism. These issues will be explored further with RACS and the Timor Leste Ministry of Health.
The following day, Sunday 7 July, the team travelled to Lose Palos to perform an assessment clinic overseen by Mr Bernardo Amaral Lopes, the nurse in charge of the local area health services. Some 31 patients were reviewed including a number of untreated cleft patients who were scheduled for treatment in Baucau the following week. Mr Bernardo noted that with more notice than one week he received of our impending visit, he would have had many more patients. The team also took the opportunity to visit the Canossian sisters who have in the past been our contact in Los Palos. Mobile phone details of both Mr Bernardo and Sr Ercia, who heads the Canossian sisters, have been obtained to assist in planning future visits.
Returning from Los Palos there was an opportunity to visit Com and re-establish contact with Mrs Robela in this village, who in the past has assisted our team in its work in this region.
From the patients seen in Baucau and Los Palos surgical lists were constructed for the first three days of the week, with other patients who presented late after word of mouth spread information about our presence, a 4th day’s operating was possible.
Cleft lip and palate repairs remain the most frequently performed operation – on this visit where 17 such operations were undertaken, the team exceeded 400 such procedures in Timor Leste since 2000. Among the cases treated was an infant whose elder sister we repaired a year ago, two brothers with clefts, and the eldest an adult who had an inadequate lip adhesion type procedure in Indonesian times. His lip was completely re-repaired and his palate repair revised – his poorly treated physical deformity and speech disability had again led to his being poorly educated and now employed in a menial job he was subjected to bullying.
During the clinics our team also reviewed an infant from Iliomar with a bilateral cleft lip and palate. This child, who remains somewhat malnourished, had had a surgical treatment of one side of his cleft lip only by a Cuban surgeon working in Dili some 2 months previously. The clinical outcome was distinctly suboptimal and this view was communicated to the RACS team leader in Dili and to several of our local counterparts in the hope that such patients are not continuing to be operated on by surgeons without an appropriate level of expertise. This patient will require many revisionary procedures in future and its long term outcome is much compromised!
All procedures performed in Baucau occurred with the RACS trained local nurse anaesthetists performing a major role in the anaesthetics, supervised by our team anaesthetist. All cleft lips were managed with a laryngeal mask as has become our norm on recent visits. The local staff again performed to the highest level and always make a major contribution.
Similarly, the local instrument nurses scrubbed and assisted in all surgical cases, whilst out team theatre nurse ensured rapid cleaning and sterilising of instruments. The efficiency of this system meant we were able to get through more cases each day than on previous visits. The limiting factor becomes availability of sterile drapes which in Baucau are generally woeful. On one occasion we resorted to a sheet of sterile plastic with a hole cut in the middle in the field of operation.
Post operative care in the surgical ward appears to be largely dependent on the input of Dr Phillip and patient relatives – the input from local nurses seems inconsistent and of variable quality.
One patient required return to theatre with a post surgical periorbital haematoma after orbital decompression for thyroid eye disease. This problem was identified by our team on its end of day ward round and the patient returned to theatre for evacuation of haematoma and lateral canthotomy. Control of facial post operative bleeding and swelling is an issue in ward without air conditioning, an inability to elevate bed heads and no ice compresses.
After a final ward round on Friday morning the team left Baucau and returned to Dili. A small clinic was held on Friday afternoon at the Bairo Pite Clinic where a number of new cleft patients were assessed for the next visit, and one long term cleft lip repair reviewed after surgery in 2001.
ORGANISATIONAL AND ADMINISTRATIVE ISSUES
1. Air travel to and from Timor Leste:
Air travel was booked by the team in its usual fashion. An excess baggage allowance was negotiated by RACS with both Qantas and Air North, resulting in a very smooth passage in both directions. Similarly, the visa waiver documents for entry into Timor Leste worked appropriately.
2. Accommodation and Meals in Timor Leste:
The appropriate hotel bookings for both Dili and Baucau had been made by Mr Sarmento – these all proceeded without event. Meals in Baucau were again at the small number of restaurants in the town. Lunches were provided for the team during the working days from the hospital kitchen, which was a useful addition.
3. Travel and Transport:
A vehicle was again provided by Rentlo at a reduced rate, albeit higher than on previous visits. Fuel costs in Timor Leste, as elsewhere, have increased dramatically increasing the costs in this area.
4. Hospital Facilities /Staff / Communication:
a. RACS Coordinator
The mechanics of the team’s visit, travel and clinics was efficiently organised and went without event. The details of the services provided by a plastic surgical team are well defined given the number of visits this team has made. Given the poor outpatient turnout in Baucau, it appears there are issues with how this information gets relayed through the health ministry to those patiens in the remote areas in need of the team’s services. Allowing for some of the special issues raised above in relation to the Mercy ship visit, there are several options for the team:
· Meet with the Health Ministry officials to establish better communication · Reactivate and expand our long standing non-government contacts in Timor Leste to improve the dissemination of the details our visits – this has already been commenced · Widen the area / increase the number of centres visited eg. Maliana, Suai, Oecussi · Produce an educational video/DVD of the team’s activities for use on local media to explain the services available – Maria Dias will explore this option further
b. Outpatient Clinics
In both Baucau and Los Palos the staff efficiently set up and organised the clinics, also providing the extra interpreting skills necessary for patients from areas where Tetum or Bahasa Indonesia was not spoken. The Los Palos staff also organised transport of their patients to Baucau for treatment. Their early return was similarly arranged with Dr Phillip to follow up the patients in Los Palos the next week.
c. Operating Theatre
Nurse anaesthetists: As recorded above and in previous reports, these nurses are well trained and contribute to the highest levels during our team visit. Their active involvement with our team helps them to maintain an expand their skills.
Instrument Nurses: The instrument nurses in Baucau are now a reasonably stable group who have worked with us on numerous occasions and now know our routines well. Within the limitations of their facility and equipment they function at an acceptable level.
d. Surgical Ward / Post operative Management:
As detailed previously, the post operative ward nursing care is somewhat variable. The active direct interaction through Dr Phillip will usually ensure the appropriate delivery of care and transmission of instructions.
e. Medical Staff:
On this visit the team unfortunately had no direct contact with any local Timorese medical staff. Whilst Dr Phillip was again a major support, there was not opportunity to meet or interact with local medical administration or doctors.
VISIT ASSESSMENT
Strengths:
Weaknesses:
HOSPITAL REFERENCIA DE BAUCAU
SUMMARY OF CLINICAL ACTIVITIES
JULY
05-12, 2008
Total patient consultation 66
Total surgical procedures 29
Cleft lip 13 Cleft palate 04 Burns 04 Other 08
SUMMARY OF TEAM ACTIVITIES JULY 5 – 12, 2008.
July 5, 2008. Team depart Darwin for Dili and travel to Bauhaus Consultation clinic at Hospital referral Baucau
July 6, 2008. Team travel to Los Palos and Com Consultation clinic in Los Palos
July 7, 2008. Surgical procedures and consultations, Baucau
July 8, 2008. Surgical procedures and consultations, Baucau
July 9, 2008. Surgical procedures and consultations, Baucau
July 10, 2008. Surgical procedures and consultations, Baucau
July 11, 2008. Team travel to Dili Consultation clinic at Bairo Pite Clinic Meeting RACS staff in Dili and Maria Dias of PAS Clinic
July 12, 2008. Team depart Dili for Darwin
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