TEAM VISIT

Rumah Sakit St Damian

Cancar, Manggarai, Flores

November 16 – 23, 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.

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.

TEAM MEMBERS:

OSSAA: Plastic and Reconstructive Surgeon: Dr. Mark Moore Anaesthetist: Dr. Phil Blum Recovery Nurse: Sr. Penelope Craig Interpreter: Anastasia Stain COUNTERPART: Director St Rafael Hospital: Dr.Sr. Natalia Maki, SSps The Head of St Damian Rehabilitation Centre: Sr. Theresya Gudepun, SSps Director of St Damian Rehabilitation Centre: Mr.Ferdinandus Jaleng Scrub Nurses: Ms. Sabina Bawu Mr. Donatus Ladus (Donny) Assistant Theatre Nurse: Ms. Florida Jedaut (Ida)

Ms. Maria Adelheid (Adel) Orderly: Mr.Pontianus Kontamat (Pak Ponti) Physiotherapist: Mr. Ferdi Jelalu Patient Registration: Ms. Tanti Nurjaya Ward Nurse: Ms. Merry Moe

Ms. Nona Karmila Sr.Lusia

Visiting Surgeon from Medan, Sumatra:- Dr. Nazwir Nazar. Sp.B (FINACS) Dr. Nova Primadina.Sp.BP-RE Resident Medical Officer: Dr.Julius

Dr. Lily Dr.Albert

Lions Club Jakarta: Ibu Nunuk

Ibu Nona

OVERVIEW

CANCAR

16TH – 23RD NOVEMBER 2013

PLASTIC SURGEON / TEAM LEADER

This plastic surgical mission, the second for the calendar year to Cancar, followed directly on from the visit to Halilulik, West Timor. Dr. Andrew Wallace and Sr. Margaret Maloney from the Halilulik team returned to Australia, whilst Dr. Phil Blum and Sr. Penny Craig joined the team returning to Bali on 15th November. Late morning on Saturday the full team boarded a Sky Aviation Fokker F50 plane bound for Labuanbajo. On arrival at the partially completed new airport terminal in Labuanbajo we were met by Pak Ferdi and loaded into a minibus. At the nearby sister’s shop we were joined by Dr. Nova Primadina (Plastic surgeon now based in Medan who accompanied us last year) and her father Dr. Nazwir Nazar, a general / plastic surgeon also from Medan. The 3 hour road trip to Cancar was largely uneventful on a road whose quality continues to improve year by year. About 15 minutes short of Cancar we experienced a tyre puncture which was quickly repaired with the assistance of passing minibus drivers. Arriving at St. Damian in the dark we were met by the smiling faces of the sisters, local staff and Ibu Nunuk and Ibu Nona from Jakarta Lions. A short consulting session was held soon after arrival with 23 patients being assessed before we adjourned for the evening at 9.30pm! Among this first group were 5 cleft patients coming from Sumba – all were booked for surgery on Monday allowing them to return home as a group on Friday – firstly a long 6+ hour minibus ride to Aimere, then connecting with an overnight ferry boat trip to Sumba. After the Sunday morning church services were completed, consulting recommenced, and continued till early afternoon. By then 75 patients had been assessed and the theatre lists for the week largely filled. Despite an Indonesian team visiting St. Rafael in the month preceeding, operating on about 25 clefts as part of the one-off Sail Komodo promotion, we still saw 37 cleft patients. These included a number returning for palate repair, having had their cleft lip repair by our team over the last 1-2 years.

Several of our old severe burn contracture patients also returned for further surgery. This including Patrisiana whose extraordinary courage in dealing with her initial devastating face and trunk burns has been matched by her stoicism through multiple surgical procedures over the last 11 years. On this visit we further released and skin grafted the burn scars on her nose.

A new case from Kupang, a 10 year old boy, came as an initial referral with similarly severe lower facial, neck and limb burn contractures. Burnt several years ago and to date untreated he has developed a secondary distortion in the growth of his lower jaw. This forward projection and overgrowth of his mandible, in concert with the drawing down and pull on his lower lip made him the biggest anaesthetic challenge for Dr. Blum during the week.

10 Year old boy with burns contractures - before surgery

……. during surgery

……..and after surgery.

As is usual there were a number of large long-standing lipomas and other benign tumours. About 15 local anaesthetic excisions were performed during the week, most of these by Dr. Nazar in the small theatre. The operating theatre was prepared on Sunday afternoon – combining the consumables brought by the team with those boxes of drugs, anaesthetic and surgical consumables left by previous teams. Surgical lists commenced early Monday morning and continued throughout the week. The smaller local anaesthetic excisions were finished by Wednesday, these largely being performed by Dr. Nazar in the smaller third theatre. The main list proceeded in the largest theatre until late on the first day when a power failure during our last case forced us to move to the second theatre. The more modern anaesthetic machine could be similarly moved so there was only minimal disturbance to routine.

Left unilateral cleft – before and after

Whilst there were slightly fewer cleft procedures performed on this visit, it did allow for more teaching and discussion with Dr. Nova – through the week she undertook most of the unilateral cleft lip repairs – producing high quality initial results, and looking to add various minor technical refinements to the technique she has been trained in, in Surabaya. With the cleft cases completed on this visit, the team has now performed almost 800 cleft surgeries since we commenced data collection in 2002. Among the cases operated on this visit was a young 9 year old girl from Ruteng, who we first treated as an infant – on this occasion she had a minor lip scar revision, and is having age appropriate dental / orthodontic intervention. With committed parents and an understanding of the treatment elements needed in clefts it is possible to have protocol based care even in the most remote locations.

Post-operatively most patients were managed in St. Damian. One cleft palate repair patient was returned to theatre early because of continuing light bleeding in recovery – she subsequently settled uneventfully. Three infant cleft patients presented unwell on day of surgery – one had chickenpox, whilst the other two improved sufficiently to have their surgery later in the week. All patients were able to leave hospital prior to the team’s departure, other than the small number of burn contracture release and skin grafting cases whose ongoing dressings and physiotherapy is overseen by the St. Damian staff and Ferdi. The team and our patients were again greatly supported by Ibu Nunuk and Ibu Nona - in addition to assisting with negotiating various administrative and financial issues that go with running such missions, they also arrange a variety of tasty Indonesian meals brought from Ruteng to supplement the usual hospital meals – much appreciated by all!! The final list ended early enough to allow the final packing, photos with theatre staff and a lengthy walk around the far side of the spider-web pattern rice paddies – this proved a step to far and several team members needed a motorcycle ride back with young locals. Friday night followed with a farewell dinner and presentation of certificates of participation to the various local doctors and nurses who worked with the OSSAA team. We then joined the St. Damian children and local staff in a fun-filled singing and dancing concert. A 4am departure on Saturday, accompanied by 2 sisters, saw the team arrive in Labuanbajo to connect with our return flight to Denpasar. Onward connections to Australia that evening saw the completion of yet another highly successful clinical and teaching mission to Cancar. The only cautionary note for missions in 2014 is the evolution in registration requirements from Indonesian Health Authorities. At this stage this seemingly requires that we:

1. Have in place MOU between OSSAA and the relevant hospitals in Cancar and Halilulik. 2. Provide approximate dates for the planned missions in 2014 to be submitted to the Indonesian

Medical Council. 3. RACS to liaise with Indonesian Medical / Surgical College to oversee the project. The exact

details of this will be further defined by communications between Sr. Angela in Halilulik and Anastasia Stain, our team coordinator.

INTERPRETER’S REPORT

Anastasia Stain – Interpreter This OSSAA Plastic trip to Cancar Flores led by Dr Mark came directly after Halilulik trip. Dr.Phil, the anaesthetist, from Darwin came on board again. We flew from Denpasar to Labuan Bajo with Sky Aviation. As usual we were picked up at Komodo Airport by our faithful friend, Ferdi Jelalu, a physiotherapist from St Damian Rehab Centre in Cancar, where we’re heading for. We popped in at the nun’s shop in Labuan Bajo for lunch before continuing our 3 or so hour mountain road trip. This time the hired mini bus had a tyre explode in the middle of our trip. Luckily the driver was quick at replacing the tyre and very calm. We all had time to get out from the bus, taking fresh mountain air and had a chat with the local children. We arrived safely at St Damian Rehab Centre in Cancar late that afternoon. Tired yet happy to see St Damian’s big family and the patients who have been waiting for us. After a short rest, we started our consultation and surgery planning in the new huge building. The number of registrations are continually high (cleft lip/palate , burn and others); it proves there is an ongoing significant need for OSSAA’s teams help there. As with other visits to Cancar, administration and efficiency by all the staff was good. Once again we were well-looked after. Everyone of us stayed fit and healthy till the end. In all there were five full operating days with 53 happy patients. A highlight of each day was the early morning walk through the villages and rural setting. Dr. Mark wasn’t just leading the team visit but the morning walk leader as well. Most mornings though I would rather sleep in as the temperature was fairly cold. It does appear that there may be some ‘changes’ with regard to fulfilling the Indonesian Medical bureaucracy requirements. I’m sure this can be sorted out so there can be a continued flow of OSSAA’s help to those who need it, particularly in NTT region. After five days of operations, the team was given a farewell dinner and a small concert by the local children who live in the compound. We were asked to participate in the dancing bit. We had a memorable evening. As always, I’m very grateful to be included on any OSSAA trip.

Bilateral clefts – before and after

Awards

Members of team and local staff