ENT TEAM MEMBERS VISIT. Rumah Sakit St Rafael. Cancar, Manggarai, Flores, NTT

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1 ENT TEAM MEMBERS VISIT Rumah Sakit St Rafael Cancar, Manggarai, Flores, NTT OCTOBER 2013

2 TEAM MEMBERS: Dr Michael Switajewski (ENT Surgeon) Dr Desmond Wee (ENT Surgeon / Interpreter) Dr Daniel Holmes (Anaesthetist) Ms Helen van der Jeugd (Anaesthetic and Recovery Nurse) Ms Bronwyn Hindley-Cooke (Theatre Nurse) St RAPHAEL COUNTERPARTS: Dr/Sr Maria Natalia Head of St Raphael Hospital Sr Aurelia Director of Nursing Ibu Sabina Bawu Theatre Head Nurse Ibu Ernawati Kabara - Nurse Ibu Adel - Nurse Ibu Ida - Nurse Bapak Donatus Ladus Theatre assistant Dr Lily GP Cancar Dr Julious GP Cancar Dr Albert Hartorio GP Cancar Bapak Mus - Anaesthetic assistant Dr Irwan Kristyoneo (Visiting ENT Specialist from Surabaya)

3 AIM OF THE TRIP The aim of this trip was to follow up on cases which had been seen but due to time constraints and the volume of cases, we were unable to surgically assist in Our plan was to see as many people as possible and advise and treat as many cases as surgically able in the five days allocated to operating. Our surgical focus was on adults, rather than paediatric patients, due to the inherent risk of secondary haemorrhage in paediatric patients after our departure. DIARY Itinerary Friday 11 th October Three members of the team departed Adelaide to Bali on Virgin Australia, with Dr Wee joining us from Perth and Dr Holmes (on his first OSSAA trip) coming from Darwin. Thanks go to Virgin Australia for waiving our excess luggage fees leaving Adelaide. We arrived in Bali, had dinner and over nighted in Denpasar at the hotel Vira Bali. Saturday 12 th October The ENT team met for early breakfast and then departed Denpasar on Sky Aviation. We had an uneventful trip and arrived at Komodo Airport Lubuanbajo on time and were met by Sr Aurelia from St Raphael Hospital. We loaded up the vehicles with all our gear and were taken for a lovely lunch at one of the newer hotels on the beach in Lubuanbajo by Sr Aurelia. After lunch we were met by a few local people that had heard that we were at the hotel, and the first of our consults began. Shortly afterwards we were on our way via the greatly improved, but still tortuous, road to Cancar. We arrived at St Raphael just as it got dark at 5.30pm, and were met by a crowd of people waiting at the hospital entrance, along with the familiar smiling faces of the staff we have met on previous visits. We were shown to our accommodations, quickly swallowed down a welcome cup of tea and set up to start consulting at 6pm. Over the next 4 hours we saw 92 patients. We had the added interpretive skills of 3 local GPs, Doctors Julious, Lily and Albert who all ably assisted with consultations, along with an ENT specialist, Dr Irwan from Surabaya. Dr Holmes set up and medically pre-operatively assessed those requiring surgery, while Sister Helen formulated a theatre list in consultation with the Surgeons. At 10.15pm we retired to our accommodations for dinner and a well earned Bintang beverage. We discussed our plans for the next week and then settled in for a well earned sleep. Sunday 13 th October After rising early and breakfasting, Dr Holmes and the two nurses headed off at 8am to the Theatres to unpack and set up for the days ahead. Dr Switajewski and Dr Wee continued with the consults and managed to see about another 30 people between 8am and 10am, before coming over to the operating theatre with another 4 additions for the ever evolving theatre list.

4 We were joined by the four local nurses and Pak Dony, and managed to get organised and commenced operating at 10.30am. Dr Irwan and Dr Lily joined us as observers for the day. We completed five long cases (Four large Hemithyroidectomies and an Isthmusectomy). Our standby 6 th case was deferred to Monday morning. Unfortunately a few of the team suffered from a gastric upset during the day and were a little the worse for wear by the end of the day. The ENT Team with local nurses and support staff Monday 14 th October The team was up early again for breakfast and were over in the Theatres and commenced operating by 8.15am. The team began with the deferred case from the previous day. We worked gradually through the list with Dr Irwan and Dr Julious observing/assisting. Pak Mus (Anaesthetic technician) arrived from Ruteng and so we decided that Dr Wee would start a case in the other Theatre. Another four very large Hemithyroidectomies and a large Parotidectomy were completed during the course of the day. One case was again deferred to the next day due to the lateness of the hour. The team retired again for the day and had a late dinner and a welcome Bintang before settling for the night.

5 The second smaller operating room utilised by the ENT team. Tuesday 15 th October The team were up early and had a bracing wash, as issues with a lack of warm water once again braced the team for the day ahead. The surgeons again agreed to use the second theatre in an effort to get an extra case or two through for the day. The deferred case from the previous day was done first. Once again we had Dr Irwan who was observing and assisting with some cases. Dr Albert, the third Cancar GP, also joined us and was an energetic addition to the team. Pak Mus worked with Dr Wee and the ENT team managed to finish six big cases between them. Six grade II and grade III Hemithyroidectomies were completed. Large neck mass being excised by Dr Switajewski Post removal of the large neck mass.

6 We went back to our accommodations and had another welcome meal and another Bintang or two, and some of the team even managed a game of cards before succumbing to sleep. Wednesday 16 th October The team was up early and decided that we needed to get out and show Dr Holmes some of the village as it was his first visit, and all he had seen was the operating theatres. Once again we attracted some attention with curious looks and shy smiles from the people of Cancar. Salamat Pagi being the phrase of the day. We went back to the hospital, breakfasted and commenced operating by 8.30am. Utilising the second theatre for a couple of the cases, we managed another six big cases for the day and once again, thinking of the local staff, we deferred one case to the following day. One of the reasons was a slight delay during the day after a large rainstorm with thunder that caused a power outage for a while. We also had an emergency case which required our skills. A woman with a pronounced stridor, with accompanying respiratory distress, due to the presence of two large thyroid goitres, required surgery. Four large Hemithyroidectomies, a large thyroglossal duct cyst/mass and a large Parotidectomy were performed. Thursday 17 th October This was our final day of operating. Utilising the second theatre, the team operated on the deferred case from the day prior which was a hemithyroidectomy case. Another four cases were also completed which included 3 hemithyroidectomies and a small parotidectomy. The team began sorting through equipment and consumables, and then started packing up during the course of the day. After the last case, and just as we had finished cleaning and packing the main theatre, Dr Switajewski did a ward round and discovered that one of the morning s cases had developed a haematoma and had to return to theatre for investigation to correct the bleeding. We quickly unpacked some equipment and took the patient into the second theatre and resolved the issue. Pre-operative thyroid goitre. The offending thyroid goitre after it s removed. Nearly 1kg in weight!

7 Once again we packed up, and, as two of the local GPs had offered to drive us to visit Ruteng, we quickly organised ourselves to set off. Our final patient returned to the ward and we all piled into a vehicle and set off to the big smoke of Ruteng which is about a 40 minute drive away. We had a quick tour and then stopped at the two churches which overlook the town. After a short shopping stop, we headed back to Cancar for our farewell dinner with the nuns. We had a lovely farewell dinner with speeches from Sr Maria Natalia, Dr Switajewski and Dr Irwan. Once again, the St Raphael nuns were lovely hosts and sang beautifully to us. The night ended early with lots of photos and promises to return again next year. We then headed back to our rooms to get organised and packed for our early departure the next morning. Friday 18 th October We were up very early, and while the doctors did a final ward round to check on the previous day s patients, we organised our bags and headed for the vehicles ready to depart for Lubuanbajo. Many of the nuns were there to farewell us as we drove away in the dark. We had a good trip through the mountains back to Komodo airport, especially with the dawn breaking and showing the mountains at their best. We arrived in Lubuanbajo in good time less than 3 hours later. Sky Aviation were kind enough to waive excess luggage expenses (After Sr Aurelia worked her magic!). We flew out on time and were back in Bali as scheduled where some of the team returned to the Vira Bali and others ventured further afield. Saturday 19 th October All the doctors set off for their respective flights to Adelaide, Perth and Darwin. Once again Virgin Australia were very generous in waiving all excess luggage fees and even Jetstar waived their excess luggage fee for Dr Holmes to Darwin. TRAINING On this trip we were ably assisted by the three local GPs, While all fairly junior in their respective careers, they were very eager to learn skills, ask questions and observe and assist with surgery where able. Their English language skills were a huge asset to the ENT team in being able to consult such a large number of patients in such a timely manner. Dr Irwan Kristyoneo was the government assigned ENT surgeon who joined us during our time in Cancar. Unfortunately his particular specialty is more upper airway ENT practice. As we were predominantly performing parotid and thyroid surgery, he was not as involved in the work as he had hoped to be. He was called on during the course of the week by the hospital staff and consulted a number of patients for the ENT surgeons when they were busy operating. Bapak Mus from Ruteng spent time with Dr Holmes and learned some anaesthetic skills and also learned some new anaesthetic medication regimes.

8 RN Hindley-Cooke was involved with teaching two of the new Theatre nursing staff some of the skills of ENT theatre nursing. Ibu Sabina and Ibu Erna have both worked with the ENT team on every visit in the past and manage well with the skills required. An area which could benefit in the future would be training some of the ward nurses in unconscious airway management in the Recovery room setting. RN van der Jeugd works at teaching post operative airway observation and management to the ward staff but this is more so when the patient has recovered from the immediate effects of the anaesthetic. GENERAL COMMENTS There were no major issues with equipment or sterilisation, As Sr Reginatus has now returned permanently to Germany, there was some concern at how the theatres would be managed and perform. Generally things ran smoothly without too much time waiting for instruments. It is not quite the well oiled machine that ran under Sr Regi s direction, but staff managed well with the workload. Cleanliness within the theatres and cleaning of equipment between cases still requires some direction, which RN Hindley-Cooke monitored and attempted to educate the nurses about with some success. SUMMARY OF CLINICAL ACTIVITY 122 CONSULTATIONS 26 SCHEDULED OPERATIONS 1 EMERGENCY CASE 1 RETURN TO THEATRE FOR POST-OP BLEEDING ADMINISTRATIVE AND PERSONNEL ISSUES The absence of Sr Reginatus in Theatre is noted, and her organisational and staff management skills were missed by the OSSAA team. Generally the Theatres ran smoothly. The two new Theatre nurses have very minimal experience but improved markedly during the course of the 5 days of operating. Knowledge levels are low but with more experience should improve. Ibu Sabina and Ibu Erna, along with RN Hindley-Cooke attempted to instruct both new nurses in the skills required. Dr Dan Holmes (Anaesthetist) managed very well and was a great asset to the team on his very first trip overseas with OSSAA. He coped with the slightly temperamental anaesthetic machine and the lack of high tech. equipment available. He has expressed an interest in returning on the next ENT trip which we sincerely hope he will. The ENT consulting went well with the presence of the three local GPs and Dr Irwan from Surabaya. There were little or no communication issues during the course of the trip.

9 The local nuns and staff were well organised and had pre-screened all patients prior to the team s arrival. This resulted in busy, but organised, consulting sessions. The ENT team, with the assistance of the local counterparts and St Raphael nursing staff, worked well together and this made for a very successful team visit. ACKNOWLEDGEMENTS Virgin Australia in Adelaide and Ngurah Rai Denpasar airports for assisting with the waiving of excess luggage fees. Sky Airways at Lubuanbajo airport for waiving excess luggage fees The Sisters and staff of St Raphael Hospital, Cancar for their dedication to their patients in the local community. The support and dedication of the Theatre and Ward staff of St Raphael Hospital. The respective Bupati in Manggarai province and the NTT Health Ministry. The Indonesian Consulate in Darwin for their continuing support of our work, documentation and provision of visas.