TEAM MEMBERS. Surgeons: Mr Philip Slattery Mr James Savundra. Anaesthetists: Dr Christopher Johnson Dr Elmo Mariampillai

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1 PROGRAM REPORT BATTICALOA, EASTERN PROVINCE, SRI LANKA 2-15 SEPTEMBER

2 Contents TEAM MEMBERS... 3 PROGAM ACTIVITY OVERVIEW... 4 Colombo to Batticaloa... 4 The Teaching Hospital of Batticaloa... 4 Clinic... 5 Theatre... 6 Wards... 7 ANAESTHESIA AND PERIOPERATIVE CARE... 8 INTERPLAST ACTIVITIES... 9 Training... 9 Official engagements RECOMMENDATIONS AND FUTURE DIRECTIONS

3 TEAM MEMBERS Surgeons: Mr Philip Slattery Mr James Savundra Anaesthetists: Dr Christopher Johnson Dr Elmo Mariampillai Nurses: Ms Linda Ferguson Ms Gillian Bathgate Colombo Members Dr Dulip Perera - Director of Plastic and Reconstructive Unit, National Hospital of Sri Lanka Dr Thushan Benergama, Consultant Plastic Surgeon, National Hospital of Sri Lanka Dr Lalindra Plastic surgery service registrar (From left to right) Dr Dulip Perera, Ms Gillian Bathgate, Mr Philip Slattery, Ms Linda Ferguson, Dr Elmo Mariampillai, Dr Thushan Benergama, Dr Chris Johnson, Mr James Savundra, Dr Lalindra 3

4 PROGAM ACTIVITY OVERVIEW Colombo to Batticaloa The team arrived into Colombo, Sri Lanka on 3 September and then travelled to Batticaloa via road. This was a nine hour 300 km road trip. (From left to right): Kingsley (our driver), Chris, Elmo, Philip Dr Jeepara, Surgeon, Teaching Hospital of Batticaloa and James The Teaching Hospital of Batticaloa The Teaching Hospital of Batticaloa is an 800-bed facility. It drains a population of over 1 million. Over 90 percent of the patients are Tamil speakers with a significant number of patients not speaking Sinhalese or English. The specialists and medical officers servicing this hospital are generally Tamil speakers, most of whom have completed their medical degrees in the medical school in Jaffna. The medical school at Batticaloa has recently celebrated the graduation of its first medical graduates. After 4

5 years of neglect in the funding of hospital facilities, there are many facility works proceeding on the hospital campus. The key co-ordinator was Dr Peethambaram Jeepara, Consultant Surgeon who did an excellent job of selecting patients, arranging the operating theatre time and other logistics during the team s visit. Also assisting the Interplast team was Dr Jeepara s intern, Dr "Lucky" Luxsen. There were two other general surgeons, an oncological surgeon, a urological surgeon, an orthopaedic surgeon, an ENT surgeon and an eye surgeon. The Director of the hospital, Dr K. Muruganandan also did everything he could to facilitate the visit. He spoke very warmly at the welcoming ceremony. Interplast s visit was advertised on the local radio and information transmitted to medical staff and other local hospitals. An article of Interplast was featured in the national newspaper during the trip. Poster on walls of hospital about Interplast visit. Dr Lucky with Linda Clinic On the first day in Batticaloa, the Interplast team conducted a clinic. Consultations were conducted in a somewhat crowded but adequate room while during the rest of the visit further consultations were done on a daily basis in another small room adjacent to the operating rooms. 5

6 Clinic Room Theatre The team reported that the operating theatres were generally very good; spacious and air conditioned although the lighting in one of the theatres was poor. There was a third adjacent operating room. The emergency surgery for the Batticaloa Teaching Hospital was conducted in this third theatre during the visit. At times they utilised 2 operating tables in this theatre to get through their usual work. Most elective surgery in the hospital was cancelled for the 2 weeks of our visit. This included elective orthopaedic surgery, oncological surgery, urological surgery and general surgery. ENT and ophthalmology surgery continued as usual in their separate theatre complex. The autoclave was adequate but did not have a drying cycle which interfered with the capacity to sterilise the portable powered drill. An operating microscope was not available and on two occasions fingers were revascularised with vein grafts inserted with loupe magnification. The operating microscope in the hospital was being used by ENT and ophthalmology when we were in need of it. 6

7 Mr Philip Slattery and Dr Dulip Perera operating together with local senior surgical registrar Wards There were separate male and female surgical wards which were very good, being light and airy and well-staffed with enthusiastic nurses. The children were generally cared for on the female ward by their mothers. There were 30 beds per ward and when there were more patients, they were given a space on the ground with a mat. It seemed that no patients were turned away and there seemed no restriction to the number of patients who could be accommodated on the ward. Senior Surgical Registrar (4 th from left) and surgical and ward staff 7

8 ANAESTHESIA AND PERIOPERATIVE CARE Anaesthetists were Drs Elmo Mariampillai and Chris Johnson respectively from Northern Hospital Melbourne and Princess Margaret Hospital for Children in Perth. Both are experienced Interplast volunteers. Batticaloa Hospital is an 800 bed teaching hospital serving approximately 1 million people; around 10,000 anaesthetics are given each year. The wards and operating theatres have the usual basic but functional infrastructure, however the medical and nursing organisation is very good with 17 anaesthesia medical officers, 4 anaesthesia trainees, two specialist anaesthetists (Drs S. Mathanalagan and S. Thevakumar) and very helpful theatre nursing staff. There was excellent interaction with the trainees and specialists during theatre sessions and future trips should consider planning for formal tutorial sessions rather than ad hoc teaching on the run. There is particular interest in the ANZCA part 1 course curriculum. Facilities are generally of a good standard. The main theatre area has three theatres, each communicating with the one next door, grouped around a small central recovery bay for two patients. Access is excellent. All three theatres are similarly equipped and are all suitable for Interplast. There are two Datex Aesteva/5 machines with S/5 monitors and only halothane. They have ETCO2 but not FiO2 or agent monitoring. The other machine is a basic but functional old Boyle machine with the same monitoring, an old Japanese piston ventilator (working well) and both halothane and isoflurane. The local practice is to induce with a Bain circuit and change to a circle system if manual or mechanical ventilation is used. On arrival, the circle system was set up with a bag attached to the scavenging outlet; manual ventilation was only possible because the expiratory valve had malfunctioned. All usual other equipment is available (including LMA s) but we chose to use the Interplast supplies. There are generally shortages of consumables such as airway circuits, LMA s and ETT since the supplies need to be ordered and approved from Colombo. We used two theatres and the other was used by the locals for emergencies. There are another 3 theatres in another location which are used for ENT, Ophthalmology and Gynae/Obs/Urology. Despite this the Interplast trip significantly disrupted the usual busy operating schedule. Theatre time seems very precious. Dr Chris Johnson teaching anaesthetic staff and junior medical officers There are six separate surgical wards and a Paediatric ward; children under 12 are usually cared for with the mother on the female adult surgical ward. The standard of care appears good, with provision of pain relief and ability to run intravenous lines in adults and children. Oral paracetamol, tramadol 8

9 and diclofenac are used but not opiates. Ward organisation was good with no confusion around operating lists or fasting; this was probably related to the very efficient and hardworking intern (Dr Lucky) assigned to us for the visit. The usual ward routine of bleeding all surgical patients (including children) for FBC and INR proved impossible to prevent. There is a newly refurbished five bed surgical High Dependency unit immediately adjacent to theatres which are staffed by anaesthesia medical officers on a 24 hour basis. It has good quality monitors and ventilators and is used for patients needing opiates postoperatively. It was simple to run a continuous low dose heparin infusion for a child after finger replantation in HDU. Both child and adult patients were in good condition with normal nutrition and little chronic respiratory disease, probably related to the admirable complete ban on smoking in all public places and overall low prevalence of smoking. The majority of cases were adult facial and upper body burns from suicide or domestic abuse with the usual airway challenges. Paediatric cases were mostly syndactyly rather than clefts as there is already an active local cleft programme. Initially the cleft patients were organised to be transferred to Colombo to be operated via the local surgeons, however we later discovered that there is a great resistance for patients to travel to Colombo for medical care. This seemed to be a combination of financial limitations, language problems and general fear of going to Colombo. Parents routinely came into theatre for induction. In summary, this is a very well organised hospital where there are few of the usual trip problems and the staff are highly motivated to work and help in the interests of the patients. It has been a privilege and a pleasure to be involved in the reintroduction of plastic surgery to Batticaloa district. INTERPLAST ACTIVITIES There were 51 operations and 114 consultations. The cases were generally burn contractures and congenital hand problems. There were no known reportable incidents which would give rise to an insurance claim. There was no mortality or known morbidity. Interestingly there appeared to be a very high take of skin grafts. There was no significant post-operative complication although the distal part of a finger re-plantation became necrotic and would require revision. Aftercare required by the local staff would consist of changes of dressing, removal of plaster casts, removal of K wires and division of a groin flap. Training James Savundra gave a lecture, Introduction to Plastic Surgery, to an auditorium of approximately 150 people including many medical students, and this was very well received. Most of those who attended had never seen a plastic surgeon nor had they heard of what that involved. The hope is that from that auditorium will be a first Tamil plastic surgeon from this region of Sri Lanka. There was much personal teaching done of nurses, interns, general surgical registrars and general surgeons. It was very noticeable that all were keen to learn. Where appropriate, practical instruction in suturing, simple excision, skin grafts, flaps, dressings and changes of dressings were provided. 9

10 James speaking at the Batticaloa Medical Society Weekly Meeting on Thursday, 13 September 2012 at 11.30am Official engagements Mr Philip Slattery and Dr Dulip Perera spoke at the welcome ceremony for our team on the first morning of the visit. Mr Philip Slattery and Ms Linda Ferguson attended a Rotary meeting and were warmly received by the Rotarian President Mr M. Ganesharajah. This was facilitated by the Rotarian chief financial officer for the hospital. Unfortunately due to a short transit time in Colombo it was not possible to make contact with Robyn Mudie the Australian High Commissioner in Colombo. Dr. K. Muruganandan, Hospital Director 10

11 RECOMMENDATIONS AND FUTURE DIRECTIONS 1. Plastic Surgery in Eastern Province, Sri Lanka: There is no Tamil speaking plastic surgeon in Sri Lanka. currently there was no local plastic surgery registrar or general surgery registrar to be trained in plastic surgery. The team were informed that Colombo trainees tend to stay in Colombo and Batticaloan trainees tend to stay in Batticaloa. There are several plastic surgery trainees in Colombo currently working in Australia but they will return to Colombo and not to Batticaloa. Recommendation: For the next few trips it would be helpful for the plastic surgery training registrar in Colombo to accompany the Interplast team to Batticaloa for further training. The overriding recommendation is that a young local trainee needs to be selected to develop plastic surgery in Batticaloa, as well as the establishment of a plastic surgery unit. 2. Future Programs: The patients of the Eastern Province of Sri Lanka are reluctant to travel to the National Hospital of Sri Lanka in Colombo. There are several reasons for this including the expense of the travel, the expense of stay for support people, and the language difficulties. It is likely that patients from the Uva Province, Northern Province, and North Eastern Province will attend Batticaloa Teaching Hospital for their plastic surgery due to the language spoken (Tamil), the closer proximity and the lower cost of travel and accommodation. Recommendation: It is recommended that programs continue on a yearly basis for the foreseeable future. There is a real need for Interplast services for this developing area of Sri Lanka. 3. Theatre Arrangements for next Interplast visit: It may be worthwhile to have further discussions with Dr Jeepara, prior to the next trip, to seek his opinion regarding two operating theatre tables in the one operating theatre, to free up a theatre and minimise the disruption to his usual operating program. Philip being instructed on the finer points of Sri Lankan tea by Dr Dulip Perera and Dr Thushan Benergama 11