The extended Interplast team at the windup cermony: Australasians, local clinical and administrative staff, sponsors & PATIENTS!

Robert Boyle, John de Waal, Margaret Humphreys, Georgina Scott, myself and Dr Sabine Vuong, (from Sydney for her first Interplast trip) were joined by Dr Djohann Wirawan, and Dr Agus from the RSU. Dr Djohann has been appointed the Periapi co-ordinator for the registrars from the CiptoMangunkusomoHospital in Jakarta.  

The coordinator of the program was once again, Dr Bambang Edyono, the Medical Superintendent of the hospital. He was very closely involved with the running of the program.

Dr Djohann continues to be a most valued member of our team. His burns unit is well established, with several burns patients in at a time, but his real love is craniofacial surgery. I have appended a copy of a recent PowerPoint presentation he made to the craniofacial society in Singapore, a very dramatic demonstration of the work that he has been able to do without the support of sophisticated tools available to most other members of that society.

The two Plastic Surgical registrars from Jakarta, Dr Karina and Dr Ery, were both very pleasant hard working young women who became very involved with the program, and whom I am sure will help maintain the goodwill we have developed with Indonesian plastic surgery. They were quite open in their expression of the value to them of the program.

The two Anaesthetic registrars from the AirlanggaUniversity in Surabaya were Dr Veronica and Dr Anna, who likewise were very skilled, and who contributed enormously to the success of the program. We were visited by Prof Edi Rahardjo from the Dr Sutomo hospital/Airlangga University in Surabaya, their professor and the source of very significant ongoing support for our Interplast program. Prof Edi had run a Primary Trauma response course in Balikpapan the weekend we arrived, so we were honored to have his presence for a second time.

The Interplast trip to Balikpapan is formally listed as a rotation program from his hospital. He treats the program as a real educational opportunity for his registrars.

Dr Veronica and Dr Anna followed up on the audit of pain management after palatal surgery undertaken by Drs Diah and Ira in 2006. The variability resulting from the use of oral Paracetamol was reduced by giving a set dose of IV Paracetamol (15 mg/Kg) in theatre to reduce variations in blood levels when children spit out or otherwise subvert oral drug intake. Pain relief was increased by the addition of a set dose of Tramadol (2 Mg/Kg IV) in theatre to our previous care pathway.

Initial results indicate an even better outcome, with no child screaming in recovery, only a few children needing extra Morphine, no significant delays in discharge from recovery (i.e., no excessive sedation from the Tramadol), adequate analgesia from the regular doses of oral Paracetamol in the ward, no increase in PONV (another potential complication of Tramadol) and discharge of all patients in less than 48 hours.

Anna and Veronica plan to report this study at an International Congress in Bali in July, and perhaps write it up for a journal. I am very pleased that we have established this annual program of quality assurance, and think it is one of the highlights of our program in East Kalimantan.

Funding

The KPC Foundation continues to support the program, together with mining support industry companies, PT Thiess, Arutmin, Trakindo, BHP Billiton and PAMA. They fund the collection and transport of patients to the RSU, and provide the team with transport and in-hospital support. They also picked up the cost of accommodation at the Novotel Hotel. The team from KPC (Pak Sony, Yuli Databua, Pak Bambang Priatmono, Louise Pesseron, and the drivers, Edi and Bondi) was ever present and supportive.

The contractors were joined this year by the Balikpapan Newspaper "Tribun Kaltim" so we had articles in the local newspaper every day. They were written in Bahasa Indonesia; Yuli has offered to translate them for us, but generally the enthusiasm was obvious, and the profile was high. The Novotel hotel also joined in the support, providing discounted rates, and support for a local program of palatal surgery.

Pak Sony is even more enthusiastic about the program, and his enthusiasm has infected the other contractors and companies. They have formed a foundation, "Senyum dan Harapan" (Smiles and Hopes) based on the title of the book KPC released in 2005. The prime purpose of this Foundation is to support the work of Interplast in East Kalimantan. KPC have shown great leadership in this initiative, which augers well for the future.

Customs

We had an unusual hiccough at the airport, where the Customs officials refused importation of our drugs for the program without leveling taxes. The Medical Superintendent of the RSU Dr Bambang Edyono was very supportive, and tried to have this annulled. Yuli had made sure they had the paperwork before our arrival, but it appeared that the first they knew of our coming was when we arrived.

KPC fortunately sorted that out after long discussions, but we never knew exactly how much tax was paid, nor why. I would imagine that Yuli won't let this happen next year.

Outpatients.

This was very well organized. The hospital and KPC limited the number of cases we would undertake to 80 again this year. We saw a total of 112 patients in the Outpatient session. Some had been deferred the previous year (notably, twins who were too young in 2006 were on the list this year), and some burns were for further work, (Yancie, wrist release, 3rd operation, and Laila, chest release 4th operation), but there was still an overwhelming flood of humanity that was somehow organized by the RSU and KPC staff. Even though we traveled overnight to arrive in time to review these patients on Monday afternoon, all went very well.

There were several patients deferred to 2008, several because they were less than our cutoff age of 6 months, but others because of the available time limitation

Work Undertaken.

80 operations were performed in total; there were 23 Cleft lips (11 under LA), 37 cleft palates (including 19 with associated cleft lips) and 20 burns release.

The hospital's plans to upgrade theatres are still in the early stages, with the total number of planned new theatres reduced to 6, down from ten planned last year. The theatres were very busy, and on one occasion, the RSU was using 4 theatres as well as the two we were using. Balikpapan is definitely a rapidly burgeoning city, and it will need the expanded theatre suite before much longer. The new international private hospital has partially opened, but as I understand it, is not doing surgery yet. The RS Ibu Restu (where we worked in 2000) has been significantly upgraded as well.

We had several children with URTI's / asthma who were deferred until the second week to allow time for treatment. At least two patients came from Central Kalimantan, an area which is quite isolated, and from which I cannot recall receiving patients before. They were brought in by BHP Billiton which mines in that remote area. The isolation of these patients may contribute to pre-existing ill health. With treatment, both these patients were suitable for surgery in the second week.

One other young patient, Achmed Yani, from Ambon, who had bilateral cleft lips done in 2006, was cancelled eventually, as his cough persisted, though his asthma had responded. His mother/grandfather were very understanding, comfortable in the knowledge that we would be returning next year. They had traveled long distances to get to our program, so we tried very hard to fit Yani in.

There were two cases where blood pressure was significantly elevated, and one young man with frequent, multiple foci ectopic ventricular heart beats. They were reviewed by the (retired) cardiologist, who could find no significant pathology. The young man with the multiple ectopics in theatre had a normal ECG when seen by the cardiologist!  They were each given a Beta blocker pre-operatively, allowing surgery to be performed uneventfully.

One young patient who had cleft lips repaired uneventfully in 2006 was noted to have a murmur this year. He was sent to the cardiologist, and diagnosed as a VSD. He will be investigated more fully during the year, and put on next year's list.

An eight year old for cleft palate repair had had a cleft lip repair undertaken at St Elsewhere's. At induction, a stricture which would not pass a 5.5 ETT was noted. The surgery was completed.  The patient was transferred to ICU for observation overnight. She was referred to the paediatrician for further management, and discharged to the ward the next day.

Equipment

As for previous years, we ran out of morphine. Morphine however was not available from the RSU pharmacy this year. We will need to increase our stocks next year..

Having a second CO₂ monitor was invaluable given last years experience, but the inline CO2 monitor has significant dead space, and meant that its use on the small children was parlous. Having a second monitor with the capability of assessing volatile Anaesthetic agents as well as CO₂ would also be very desirable.

We ran short of significant amounts of other equipment, most of which could be sourced from the RS Pharmacy, but blunt drawing up needles were not available. Georgie has kept a record of the items we need to bring next year.

Use of Volatile Anaesthetics.

We can no longer purchase Halothane in Australia. Our plan was to get the hospital to source it from Indonesia and to then charge us for its use. However, after a couple of days of using the hospital vaporizers, it became obvious that they had a very unreliable output, reflecting the fact that their service interval was probably well overdue! They had relatively new Sevoflurane vaporizers so we elected to use those solely. We had only brought one bottle of Sevo with us, and the hospital supplied us with more. We signed for each lot of volatile supplied, and post operative bottles of oral Paracetamol, etc. Currently there is a hiccough re what was received, but that should be relatively easily sorted, and we will pay the RSU for supply.

Post Operative Recovery Unit.

There has been a marginal improvement over last year, but this is still the weakest part of the theatre suite. We will continue to work on improving the staffing. With two Anaesthetists this year and with the much better outcome for post-palatal surgery alluded to earlier, it was less of an acute problem for me.

Theatre safety

Margaret was pleased to see that the initiatives that she set up last year (cleaning floors and refreshing suction equipment, as well as development of procedures such as sharps management), has continued. She has extended her teaching further this year, which will flow through to better theatre outcome overall.

Other additions to the team

Kel Hobby, from the Rotary Club of Sorrento, whose club had sponsored the Australasian costs, came as the Rotary Observer. Kel fitted in very well, and helped wherever possible, distributing presents to children in the wards, helping with some plumbing problems, etc.

Even though Kel was amazed at what he saw, he said that the time he spent was a bit long, and that one week would have been plenty. I think that he is right, as it does become fairly repetitious.

Debbie Shiell, the new Community Relations Manager for Interplast, came on her maiden Interplast trip as an educational experience. She was absolutely fantastic to have along, able to take some of the load off Margaret and Georgie's shoulders. She also shouldered most of the responsibility of entertaining Bernadette Whitelum the AusAID representative from Jakarta, who came to represent the Australian Ambassador, Mr. Bill Farmer.

Mr. Farmer's visit was aborted at the last moment, putting out bushfires arising from the NSW coroner's clumsy attempts to get the Governor of Jakarta to testify at a hearing into the murders of 5 Australian newsmen in East Timor in 1975. It was a shame that he did not come, as the hospital and KPC had put a very large amount of effort into the day, organizing security etc. A large number of guests from health, government and mining circles, had come to Balikpapan to meet him.

Significant developments this year.

• The Airlangga university in Jakarta treats the rotation of Anaesthetic registrars to Balikpapan as part of their formal rotations.
• We had two plastic surgical registrars, each present for the whole program, working with our team. I would not be surprised to find that the CiptoMangunkusomoHospital in Jakarta will likewise be treating this rotation as part of their formal training program as well.
• The addition of an extra Anaesthetist was very useful, and will I hope allow for some secession planning.
• The development of the Senyum dan Harapan ("Smiles and Hopes") Foundation to secure future funding for Interplast in East Kalimantan
• The addition of the Tribun Kaltim to the above list of donors guaranteed maximum publicity, with daily articles in that newspaper
• The addition of BHP Billiton to the contractors list, and with it referrals from the very isolated areas of Central Kalimantan
• The visit by the AusAID representative, Bernadette Whitelum
• The further almost complete involvement of the hospital in our program

The future.

The team continues to enjoy working in East Kalimantan. I would expect that we will essentially have the same team next year, though Dr Sabine Vuong may be taking maternity leave!

In future monitoring equipment acquisition plans for Interplast, consideration of dead space should be given, with side-stream or out-of-circuit rather than in-line CO2 monitoring being purchased.

John Oswald

For the Interplast team, Balikpapan, East Kalimantan, 2007