Report to Interplast on trip to East Kalimantan June 2006
The Interplast team to East Kalimantan for June 2005-6 was
reformed for our 11th visit to East Kalimantan, and our 4th visit to
the RSU Dr Kanujoso Djatiwibowo at Balikpapan.
Robert Boyle
, John de Waal, Margaret Humphreys, Georgina Scott and I were joined
by a Rotary Benefactor from Melbourne, Mr Andrew
Duncan. Balikpapan
members of the team were Dr Djohann Wirawan, Dr Soleh and Dr Agus from the RSU.
The coordinator of the program was Dr
Bambang Edyono, the Medical Superintendent of the hospital.
Dr Djohann continues to be a most valued member of our team.
He has formed the nucleus of a burns unit, and was caring for several patients
with acute burn injuries in the RSU when we arrived, undertaking primary burn
management. He has a more senior position in the hospital this year than
previously. The hospital plans an
expansion of their theatres, with 10 new theatres to be built adjacent to the
current suite. It is not inconceivable that Dr Djohann might have one as a
dedicated burns theatre.
We were joined by a plastic surgical registrar from Jakarta, Dr Dedy, the
sixth such registrar to have worked with our team. These registrars will be
future leaders in plastic surgery in their country. This augurs well for the
future. Dr Dedy seemed unaware of the opportunities, and was initially
uninvolved, but after a slow start became a very valuable member of our team.
Prof. Edi Rahardjo from Surabaya again supplied two Anaesthetic residents
who had undertaken their paediatric Anaesthesia training. Dr Diah Widianty and Dr Ira Pitaloka were very,
very competent and ultra enthusiastic, and an integral part of our team. They
were very professional in the preoperative assessment and preparation, and
post-operative review of patients. They were very eager to learn. We had two
blind nasal intubations to demonstrate, and several difficult airways to
manage.
Like their predecessors before them, they undertook an audit
of the post operative management of pain relief in association with palatal
surgery. They will present a paper on the audit outcome at the Australian
Society of Anaesthetists National Scientific Congress in Coolum in October. The
Australian Society of Anaesthetists will fund the expenses of one of the
presenters, and Interplast has volunteered to fund the costs of the other.
The Anaesthetic
residents and their audit have become an essential part of our program. They
will be welcomed back by the RSU next year.
Funding
The KPC Foundation continues to support the program,
together with mining support industry companies, PT Thiess, Trakindo and PAMA,
as they have in previous years.
As well, we were accompanied by our own Rotarian benefactor,
Andrew Duncan, who had funded the
program by himself. He had some previous involvement with the mining industry
in East Kalimantan, and was eager to combine
his enthusiasm for Interplast with an opportunity to support the local
community. Andrew fitted in well with the team. I will be pleased to see what
he, from an objective point of view, thought of the program if he puts in a
report. I think he was staggered by the rate and amount of work, but also by
the involvement of the team with the entire community, and by the technology
involved.
Pak Sony is even more enthusiastic about the program, and
invited us to Sangatta for the weekend, for dinner at his house. Whilst we were
in Sangatta we were asked to review the Sangatta Lama RSU, with a view to
possible use in a future Interplast program. Evidently there has been pressure
from Sangatta sources for the KPC foundation to fund projects in the region of
the mine. However, the hospital fell way short of the mark.
Nonetheless, the community is booming in Sangatta Lama, and
there are plans to build a major new hospital in the area. Going by the size
and grandeur of the government buildings that have been built already, little
expense will be spared. If that is the case, there may be an opportunity for a
second team to go to this planned new hospital in the future. The current team
feels that the goodwill they have in Balikpapan
would be squandered if they were to shift sites. All team members look at
continuing going to Balikpapan
for the foreseeable future.
Outpatients.
This was even better organized than last year, though with 110
patients seen on Monday afternoon, it was a sort of controlled chaos. The
hospital and KPC limited the number of cases we would undertake to 80 for this
year as for previous years. There were 30 cases we could not undertake, and
these have been transferred to next year's waiting list. We deliberately did
not do any child under 6 months. Parents were happy to accept this offer.
This year there were 25 patients from South Kalimantan and
for the first time, 8 patients from Central Kalimantan and one from far north East Kalimantan. There were also two patients from beyond
Kalimantan, (one from Ambon, with both cleft
lip and palate repaired, and one from Java for revision of burns surgery). The total population of Kalimantan is 9
million; Balikpapan
at present is the only facility where more sophisticated surgery can be
undertaken. We will not run short of work in the foreseeable future.
There were two children picked up with possible congenital
heart disease at the outpatient scan (Chest X-ray and "Complete Blood Picture").
Another had failure to thrive. There was no patient with malaria this year, but
several with chest infections who were deferred until later in the second week
for pre-operative optimization. Those patients who missed out because of
medical reasons were referred to the paediatricians, and will be seen again
next year.
Work Undertaken.
80 patients were operated on, with a total of 95 operations
performed, counting cleft lip and palate procedures as separate operations, but
counting burns procedures as one event. As for previous years, 70% were cleft
lips and or palates, and the remaining 30%, burns. As noted previously, there
were several difficult intubations amongst the burns. There were also 28 change
of dressings done in theatre in the second week.
The average age of the children was significantly older than
last year, helped a little by the 6-months-old cut off. However, as in previous
years, the complexity of the cases we undertook was high, with a total of 35
palate repairs undertaken.
We continued our program of operating on major burns cases
in the first week, which allowed for review and further management over the
second week. We did of course still
leave much post operative management of these burns to the very competent Dr
Djohann. One patient (Herino Rinto, see photo) requiring an awake nasal
intubation, was transferred to the ICU post operatively, principally so that
she could be in a bed which could be sat up.
Equipment
We ran out of most Anaesthetic drugs
as in previous years, but had no problem acquiring them from the pharmacy at
the RSU. KPC was happy to supply oral
Paracetamol elixir and Nurofen for children, which they purchased from a
pharmacy in Balikpapan.
This saved significantly on shipping weight, and thereby expense.
There were no Plexufix needles for
arm blocks, and some other items known to have been packed could not be
found. We are uncertain where these
items went.
We took over scavenging equipment
for the other three theatres, so now all five theatres are scavenged for
volatile anaesthetics. The second
theatre had a sophisticated vital signs monitor which had been purchased, I
believe, personally by Dr Soleh, immediately after our visit last year.
There was a saturation monitor and
an ECG in a third theatre which we occasionally used.
Dr Bambang believes the new
theatres will be fitted out with new equipment, as has the ICU, (which has been
very elaborately fitted out). We shall live in hope!
Recovery.
This continues to
be the weakest link in the program. I spent significant time in the recovery
managing patients post operatively, because the Anaesthetic technicians had
other duties. Their workload normally is such that patients can apparently be
left unsupervised, so the Recovery is not usually staffed! Or equipped! But
with our workload of cleft palates, such a routine is unacceptable. There is no
equipment to speak of in the recovery. We would be lost without the portable
saturation monitors. Possibilities for cross infection are also high.
The new theatre
suite will have a much larger recovery. Perhaps funding will be organized for
permanent staff, equipment and dressings.
Nursing Students
As for last year,
there were a number of nursing students formally attached to the team. They
were well trained and very enthusiastic. They were there to learn, but the team
found them to be a great resource.
Significant
developments this year.
·
The development of a primary burns management program in the
RSU by Dr Djohann, with funding by the RSU for non fee paying patients.
·
The planned building of ten new theatres over the next 12
months.
·
Possibilities for an Interplast team to visit Sangatta in
the median term.
·
A strong Rotary club is developing out of the Le Grandeur
hotel (re-born Dusit Hotel). I addressed them at their meeting, as they had no
idea what Interplast did. They were enthusiastic to support it and other
initiatives in the future.
·
The closing ceremony, normally a very emotional affair was
even more so this year when it was addressed by one of our patients Laila
Hariani, a badly acid burnt patient who has progressed dramatically since her
initial operation three years ago.
·
An even closer association with the Director of Medical
Services, Dr Bambang Edyono. He has an enormous enthusiasm for the program,
which was highlighted by his open introduction of the patients to the team on
the afternoon of our arrival, in the foyer of the hospital, before the
outpatient session.
The
future.
The new
International hospital being built in Balikpapan
has still not been completed. This might up the ante for medical developments
in Balikpapan. As
for last year, each of the current team, from Australia/NZ and Indonesia, is
enthusiastic to come on this trip again next year, and pick up where we left
off.
John Oswald
For the
Interplast team, Balikpapan, East
Kalimantan, 2006
