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TEAM VISIT

RUMAH SAKIT KATOLIK MARIANUM, HALILULIK

9– 14 November 2013

Team Leader’s Report

Dr. Mark Moore AM, FRACS

Plastic and Craniofacial Surgeon

Implementation of Dr. John Hargrove’s mission in East Timor and

Eastern Indonesia: providing a specialist surgical service to the

disadvantaged where the service is not available or affordable.

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AIMS AND GOALS 1. The ongoing provision of a plastic and reconstructive / cleft lip and palate

surgical service to the people of Flores and the surrounding islands of Nusa Tenggara Timur (NTT),

Indonesia.

2. To continue to work with our longstanding local counterpart medical, nursing

and physiotherapy staff at Rumah Sakit St Damian and St Rafael, Cancar and assist them in

developing their skills for the delivery of services to those patients with physical disability and

deformity.

3. To support capacity building by providing skills transfer more widely in Indonesia by incorporating

local specialist counterparts in the visiting team.

4. To continue to develop links with other charitable support services in Indonesia whose missions

overlap and compliment that of OSSAA.

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TEAM MEMBERS OSSAA MEMBERS Dr. Mark Moore : Plastic & Reconstructive Surgeon/ Team Leader Dr.Andrew Wallace : Anaesthetist Sr.Margaret Maloney : Theatre/Recovery Nurse Anastasia Stain : Interpreter COUNTERPART: Rumah Sakit Katolik MARIANUM, Halilulik NTT Sr.Angela Salome : Director Dr.Suroso : Marianum Hospital Responsible Surgeon Dr.Risky Ilona Saputra : Resident Medical Officer Dr.Rudyanto Wiharjo Seger : Resident Medical Officer Sr.Hildagunde : Nurse Helena Parasi : Recovery Nurse Richard Asamai : Anaesthetist Nurse Adis Talan : Scrub Nurse Tilda Kase : Theatre Nurse Natalia Kleden : Theatre Nurse Medical personnel for observation and teaching session during OSSAA visit: Dr. Ricky Cornelius Tarigan (from Medan, North Sumatra)-Cannosan Clinic in Nurabo Dr. Yovita Gunawan(from Ngawi, East Java)-Kefa Hospital Dr.Nur Wahid (from Banyuwangi, East Java)- Puskesmas Haekesak Dr. Juanita Widodo(from Atambua)-Puskesmas Silawan Dr. Carolina Gonsalia Oemata (from Atambua)-Puskesmas Atapupu Dr. Yolinda Leonaya(from Atambua)-Puskesmas Haliwen

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OVERVIEW

This plastic and reconstructive surgical mission to Rumah Sakit Katolik Marianum (RSSKM), Halilulik

was the first for four years, after regular visits to the region in the years 2007 – 2009. There was some

uncertainty after the last visit as to the ongoing requirement and wish for plastic surgical teams. After

communication from Sr. Angela Salome Ssps, Director of RSKM, earlier this year, that there was a need

for surgical treatment of cleft lip and palate and burn patients, we agreed to add a visit to Halilulik in

the week prior to the Cancar visit. Appropriate pre-visit approvals were sought and obtained from the

relevant Indonesian authorities, this being overseen by Sr. Angela. Due to the domestic travel

arrangements within Indonesia between the two sites, the Halilulik visit would comprise one day of

consultation and four surgical days.

Arriving in Bali on Friday, the team travelled to Kupang on a Garuda Indonesia flight late on Saturday

morning. After being met by two Ssps sisters we were conveyed to a Kupang restaurant for lunch,

before our onward road trip. The 5+ hour minibus drive to Halilulik was broken for dinner in

Kefamenanu, before reaching our destination mid-evening. A short formal greeting from Sr. Angela,

her team and the local doctors was followed by the team settling in to their accommodation in the

doctor’s house across the road from the hospital. Ibu Nunuk and Ibu Nona from the Jakarta Lions

were also present to welcome the team.

Consultations commenced on Sunday morning after church and were held in the ward area adjacent

to the main hospital. The clinic was well organised, with patient details and relevant clinical data

recorded. A number of the local junior doctors were in attendance, allowing for teaching on a range

of cases. Twenty patients were assessed during the morning, with a further three cases arriving early

evening. Preliminary surgical lists were constructed and distributed to the theatre and ward.

Andrew Wallace teaching local doctors

The afternoon was free to familiarise ourselves again with the operating theatre, for Dr Wallace on his

first visit, to assess and set up the Perlon anaesthetic machine and the rest of the team to sort

instruments and consumables. The latter included retrieving from the storeroom a case of sutures

dressings, etc. left there since 2009. This proved invaluable in terms of a backup supply of materials

and locating a cleft palate mouth gag. We had mistakenly left our palate gags in Adelaide, so this

fortuitous find allowed for palate repairs to proceed unhindered. Several hours were spent on Sunday

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afternoon visiting the nearby town of Atambua in the company of Dr Rudy and Rocky, a Halilulik

resident who had met us on previous visits.

Pre/post operative bilateral cleft repair

The surgical list began on Monday morning. After a slow start, as everyone familiarised themselves

with their new surroundings and new colleagues, it was possible to perform operations on eight

patients. The day was somewhat longer than planned, with issues including the anaesthetic machine

and regular changes of scrub nursing staff.

On Tuesday the Perlon anaesthetic machine developed a gas leak that made it unusable so Dr Wallace

converted to using the older small soft Lander-type halothane vaporiser. Thereafter all the

anaesthetics proceeded uneventfully. The theatre team also settled on a single nurse, Pak Adis, as the

regular scrub nurse. This, in concert with Ibu Helen assisted by Marg Maloney in recovery, ensured all

cases proceeded smoothly. Dr Ilona and Dr Rudy, the resident medical officers at RSKM, as well as five

similar colleagues from Atamua, Kefa and other districts participated with patient care all week. There

were ample learning and teaching opportunities as they assisted surgically and with anaesthetics on

all four surgical days. They also assisted in post-operative care and ward rounds and will oversee those

patients in need of longer ongoing care after our team’s departure.

At weeks end we has assessed 40 patients, 30 of which were cleft lip and or palate, including four

patients previously treated by our team. Four patients with burn related scarring were reviewed, 2

requiring surgery, whilst 1 case was offered surgery but refused. Probably only 2 cases were outside

the team’s area of expertise, confirming the excellent / triage selection process by the local staff. The

cleft patients presented at a range of ages with a number of more complex, wide complete cleft lip

and palates. This is a different spectrum to that which we see in nearby Timor Leste - many

incomplete cleft lips. A possible explanation could be recent short cleft missions by Indonesian teams

(eg Sail Komado) who may have performed surgery on some of the more straightforward cases. As

many cases also had cleft palates, they have been waitlisted for a return visit in 2014, after repairing

their lips this time.

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Neck burn contractures and release

Recovery and post-operative care was at a very high level, the routines having been well developed

between local nursing staff and our regular OSSAA general surgical teams. It was a pleasure to

participate twice daily on ward rounds with local nursing staff whose attention to detail re patient

observations etc. was exemplary. Patient discharges were arranged and discussed prior to our team’s

departure.

4 year follow up bilateral cleft repair

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On our final evening a formal presentation and thanks for our visit was arranged by Sr. Angela. This

included a speech by Sr. Angela and Dr. Mark Moore, followed by presentation of certificates of

participation to the junior doctors who worked with the visiting team.

Certificate provided to participating doctors

The team departed early Friday morning for Kupang to connect with our return Garuda Indonesia

flight to Denpasar. Dr Andrew and Sr. Margaret then continued on to Australia on overnight flights,

whilst Dr Mark and Ibu Anastasia joined colleagues to work in Cancar the following week.

Patients, Nuns, staff and team members

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Specific issues deserving of further comment include:

1. Air travel:

- Virgin Australia staff out of Adelaide were very supportive and waived any excess

baggage claims.

- Domestic Indonesian flights were delayed in both directions and excess baggage

charges continue to be made despite the nature of our programme. Junior-level staff are not able to

take responsibility for any such decision.

- The possibility of air travel between Kupand and Atambua was again raised, given

the long duration of this drive by road. Garuda staff in Kupang indicated that in

2014 they would be commencing daily return Kupang – Atambua flights which may make this a

reality.

2. Hospital facilities:

- The RSKM appears well organised and administered by Sr. Angela with the clear support of

the local health authorities. The systems of patient management set up with the general

surgical teams of Dr Bob and Dr Brian were easily applied to our team.

- The operating theatre could well do with an improved theatre light and maintenance of the

anaesthetic machine as noted above. Otherwise the facility and nursing staff provide

excellent, professional support for the visiting teams.

- The accommodation area for the team is clean and well maintained, it is hot and the team

required fans for each bedroom, which have been left for future visiting teams.

- Meals which are served in the theatre complex are were diverse, healthy and appetizing,

setting new high standards for other locations.

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3. Administration / registration issues:

- During the week discussions were held between Sr. Angela, Ibu Anastasia and Dr. Mark

regarding planning for future trips, the Indonesian registration requirements and future

involvement of RACS The anticipated process for developing and organising team visits seems

to be approaching its final form and will likely commence in 2014.

4. Summary:

- This return plastic surgical mission to Halilulik can be judged to have been highly

successful clinically, teaching and training wise and politically and administratively, setting the

scene for an ongoing program.

5. Local charitable support

- The role of Ibu Nunuk and her colleague Ibu Nona from the Jakarta Lions Club has proved

invaluable both in providing financial support for local hospital costs to patients, and in

negotiating and providing guidance to the team in the evolving medico-political climate in

Indonesia. We are extremely grateful to them for their ongoing support of our team.

Finally to Sr. Angela and her team, whose welcoming of us into the RSKM “family”,ensured the overall

success of the visit.

Before and after bilateral cleft repair

Go girls!

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Interpreter’s Report - Anastasia Stain

We left Adelaide on the 8th of November 2013 in the morning with Virgin Australia. Arrived at Bali Airport uneventfully—all went smoothly passing through the Customs. As usual we stayed overnight in Bali then flying with Garuda Indonesia to Kupang the next day. In Kupang we were picked up by the sisters for the six hours or so on a road trip to our destination, Rumah Sakit Katolik Marianum, Halilulik, run by SSps order of nun. My first ever OSSAA trip to Halilulik, Timor ! Upon arrival in Halilulik we had a formal greeting from the staff and we were each given a traditional scarf as a welcoming gift; this happened at about 9 p.m. local time so there was no time for anything except a good nigh’st sleep. It was a hot and humid night in fact. The next day, being Sunday, we started our consultation and forward planning for the upcoming operations—setting up theatre and scheduling and what not. We still had time to see Atambua that afternoon which is nearly an hour’s drive. The next four days (due to the long hour road trip from Halilulik to Kupang and also the flight time arrangement, we weren’t be able to stay until weekend) were normal operating and ward round days and also ‘catching up’ time with the Director of the hospital, Sr. Angela Salome. Thanks for sharing. My impressions of the Marianum Hospital are that it is a very well-administered hospital and extremely efficient. This certainly made our task a lot easier. The staff looked after us very well. They kept saying that OSSAA is their ‘big family’. Although this was only a short five days visit, due to the fact that Dr Mark Moore led another team straight after Halilulik visit to Cancar, Flores, the visit was very successful. I personally enjoyed it very much. I would once again extend my gratitude to the great team for such ‘ A’ trip and for including me on board. Looking forward to the next visit! ACKNOWLEDGMENTS

Dr. Andrew Wallace, our Anaesthetist Doctor, WELCOME ! His first trip with OSSAA, survived many challenges and rose to

the occasion with good humor and calmness.

Kalyra Knitting for donating the Teddy bears and toy trucks

Duncan Armstrong

Teruno syringes and needles

Johnson & Johnson for donating sutures

Alison Kelty - XANADU, for donating plastic bracelets for the patients

Royal Adelaide Hospital- Staff Room, Sterilising Dept.

Virgin Australia- for waiving excess baggage

Marianum Hospital in Halilulik for their hospitality, above and beyond what was required.

Sr Hilda the masseur, Vero (laundry lady), Chellamoy(housekeeping) and all the nurses for their efficient and professional care.

Ibu Nunuk, LIONS CLUB Jakarta Division for her continuing support for the Cleft Lip/Palate patients with their transport and hospital expenses.

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Sister Margaret giving out soft toys

Sister Hilda giving Mark a much needed massage

Recovery sister Helen with young cleft patient

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Post-op patients

Mark teaching a local doctor

A young cleft patient with the teddy bear given by the Kalyra knitting group