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Northern Territory Department of Health Library Services Historical Collection
AUSTRALIA/INDONESIA 'SISTER HOSPITALS'
N.T.T. PROVINCE
The Reconstructive Surgery Program
An Overview
January 1993
COLLECTIO
DL HIST GRAVE, MD; FRACS; DTM&H CEN, MB; BS: FRACS
Royal Darwin Hospital PO Box41326 CASUARINA NORTHERN TERRITORY 0811 AUSTRALIA 617.37 LE, MBE; RM; FRCNA
AUS ,SRN 1993
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ABSTRACT lERRlTORY HEALTH SERVICES
1. For some 2 years there has been a viable Reconstructive Surgery Program working under the banner of the AUSTRALIA / INDONESIA - SISTER HOSPITAL scheme centred on Soe and Kefamenanu Hospitals in Timor, Indonesia
2. The program is designed to cater for patients with deformity or disability arising from trauma, burns poliomyelitis, leprosy, congenital defects and other problems.
3. Resconstructive surgery is the lynchpin of the program since its results can been seen by all, are immediate and have the potential to open the door to Public Health initiatives.
4. The Pusat Rehabilitasi Yakkum, Yogyakarta, has:
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(a) sent a technician to Soe to make prostheses
(b) trained a field worker and an orthopaedic shoe maker for the Y ayasan Asuhan Penyandang Cacat in Soe
( c) accepted patients in Y ogyakarta for rehabilitation
In turn we have accepted patients in Soe and in Darwin from Yogyakarta.
The Pusat Rehabilitasi Yakkum, the Yayasan Asuhan Penyandang Cacat and the Australia I Indonesia Sister Hospital program continue to forge and strengthen links to mutual advantage.
Rotary (Darwin) has identified funds to upgrade operating theatre facilities in Soe Hospital over the next 2 years.
We have received two grants for the past financial year: namely, one from the Australia I Indonesia Institute and also one from Smith and Nephew, both of which will ensure that the Reconstructive Surgery Program will continue for a further year. We also received a grant for the first year of the program from AID AB under their Professional Develop- ment Scheme (i.e. the previous financial year).
The Leprosy Mission (Singapore) has responded to a request for aid in leprosy control in N.T.T. Province, Indonesia, resulting from an initiative from the Sister Hospital program and will shortly begin work in West Tim or.
The RECONSTRUCT/VE SURGERY program should be seen in the context of one which, although in itself small, is capable of making a profound impact on peoples' attitudes thereby opening the door to broader Public Health initiatives.
The need for Reconstructive Surgery following the recent earthquake tragedy at Maumere (Flores) should be explored in coming visits to Indonesia.
Links with East Timor should be re-established and we should also look to forging l ~ ~.
with the rehabilitation Centre in Ruteng.
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A TIMORESE VILLAGE
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TIMORESE WEAVING•
In 1990 the Royal Darwin Hospital, the Professor Johannes Hospital in Ku pang and hospitals in S oe and Ke.famenanu forged a 'SISTER HOSPITAL' relationship. This was formally ratified by the Northern Territory and Indonesian Governments, the over- riding intention of which was to enhance relationships in the Health arena between Darwin and Indonesia - our nearest neighbour. This has already resulted in a number of important exchange visits between staff from the various hospitals and the Department of Health. It has the potential to enrich and improve medical and surgical practice in the Northern Territory on the one hand, and to work together with Indonesian personnel, on the other, in the area of Professional Development. So far we have focussed on 2 main issues:
1. The development of a viable Reconstructive Surgical Program based on Soe and Kefamenanu hospitals with the potential to expand to other hospitals within the Region.
2. Staff exchanges between Darwin and N.T.T. Province, Indonesia.
NUSA TENGGARA TIMUR
THE REGION
Darwin is the centre of a large area embracing most of Australia to the south and much of Indonesia, Papua New Guinea, Brunei, part of Malaysia and most of the Philippines to the north.
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Initial forays were made in the field of Leprosy Control. This proved to be a
much larger task than originally anticipated and a joint approach was therefore made by Health Authorities in Indonesia and by ourselves to various International Agencies, resulting in substantial aid from the Leprosy Mission (Singapore). We subsequently saw a more significant role that could be played together with local Yayasans in the broader field of Reconstructive Surgery, dealing with deformity and disability of a wider variety. resulting not only from leprosy but also from poliomyelitis, burns, congenital defects, trauma and other causes. We therefore centred our activities on Soe Hospital, at the request of the Department of Health, Kupang, and later expanded to include Kefamenanu at the request of the Bupati of T.T.U. Regency, West Timor. We see the central location of Soe as important, but also believe that, as resources i rnprove, the program could be expanded to include other Regencies within the Province.
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Most deformity and disability is quite advanced by the time patients present at clinics, but a lot could be prevented if people presented earlier. One of the more common deformities is that of CLUB- FOOT. The patient shown in these pictures will require extensive surgery to correct the deformities in his feet.
RECONSTRUCTIVE SURGERY:
Reconstructive Surgery can make a profound impact on patients' attitudes. It produces immediate results and can be seen by all. It has the potential to return people to the Workforce. It can prevent permanent disability, especially if it is tackled early, but above all it can open the door to Public Health initiatives. The pictures that follow demonstrate some of the problems encountered in the eastern Provinces of Indonesia. In Nusa Tenggara Timur we have had the good fortune to work in close co-operation with local Yayasans - namely the Yayasan Asuhan Penyandang C acat in Soe and the Leprosy Foundation in T.T.U.
Regency. We have also had vital help from the Pusat Rehabilitasi Yakkum (Yogyakarta). They have lent a orthotic technician to the Yayasan in Soe, together with the logistic backup to make limbs and prostheses for disabled patients. They have also trained Field Workers in Y ogyakarta and accepted patients from Soe for rehabilitation. In turn, we have accepted patients from Y ogyakarta for Reconstructive Surgery in Soe and in Darwin.
Leprosy patients lose sensation in their feet and hands and frequently develop disabling ulceration. Feet need regular attention, but this can be done at any PUSKESMAS if staff have the proper training. Where local Yayasans exist, such as in Soe and Kefamenanu, there is the real potential to improve the overall care of leprosy patients with the simplest but eminently affordable means.There are 2 important principles:
1. Hand and foot-care is simple and inexpensive and within the capacity of any PUSKESMAS.
2. If you care for deformity you will convince patients that it is worth their while to take important anti-leprosy medication. In this way the care of deformity can affect Public Health issues.
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Burns are very common, especially those caused by kerosene heater accidents. They can cause severe contractures, but a lot are relieved by skin grafts. This young girl will need extensive plastic surgery to relieve the contracture in her armpit, but it is relatively simple to correct and can be done in local hospitals such as those in So e and Ke fame nan u by the combined Australian / Indonesian team working on the Reconstructive Surgery Program.
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Following a formal amputation of the deformed stump at the local hospital, he was fitted with a prosthesis by a technician on loan from the Pusat Rehabilitasi Yakkum (Y ogyakarta), working in Soe for the Ya ya s an Asuhan Penyandang Cacat.
This young man from Kefamenanu was born with a serious deformity of his leg and foot resulting in significant shortening and the need to bend his other knee permanently in order to walk.
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Filariasis still occurs in Timor and ·can be very disabling to the breadwinner. This man will also need a prosthesis.
This young boy from a village near So~
(Timor) was bitten by a snake. To save his life the villagers chopped off his foot. He was fitted with a prosthesis by a technician on loan from the Pusat Rehabilitasi Yakkum (Yogyakarta).
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These photographs show disabled staff working in the Pusat Rehabilitasi Yakkum in Y ogyakarta. We believe that a long-term, and mutually advantageous relationship is developing between the staff there and the Y ayasan Asuhan Penyandang Cacat in Soe.
I The Pus at Rehabilitasi Y akkum (Yogyakarta) has been extremely [ generous in training staff from Soe . (Timor) for shoemaking, prosthetics and Field Work. They have also accepted patients for rehabilitation in Y ogyakarta.
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Simple but disabling deformity like this, occurring in a young boy, can be improved by Reconstructive Surgery.
This can be readily performed at local hospitals like those at So e and Kefamenanu.
This young man's hand was burned in Java, leaving him with a useless thumb and contracted fingers. Since he was a Field Worker with the Pusat Rehabilitasi Yakkum in Y ogyakarta, he was sent to Soe (Timor) for Reconstructive Surgery. He needed two operations to correct the deformity and these were done by the combined Australian / Indonesian Reconstructive Surgery team at Soe Hospital. We see this sort of work as an important part of the developing relationship between the Pus at Rehabilitasi Yakkum and the Yayasan Asuhan Penyandang Cacal.
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Bum contractures of the elbow are very disabling since it is impossible to extend the arm fully. This sort of deformity can be corrected by Reconstructive Surgery and skin grafting. It does not need sophisticated equipment and can be done at peripheral hospitals like those at Soe and Kefamenanu.
This young boy probably has severe, crippling juvenile rheumatoid arthritis of the knees. He had been sitting in a village for many months with his knees bent so that they became fixed in this position. By releasing the tendons at the back of his knees the legs can be partially straightened, but he also needs physiotherapy. Although the treatment is not complicated, the problem is not easily solved because his village is in an extemely remote part of Timor.
This underlines the need for Field Workers and Physiotherapy Aides who can visit his home rather than expect him to come to the hospital too often.
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Birth Deformity or that occurring in infancy, such as Poliomyelitis, can lead to severe disability. If patients live a long way from large clinics or hospitals it can go undetected for a long time. Patients may also fear surgery and sometimes hide deformity because they are ashamed of it.
fracture occurring in early life. It is technichally feasbile to correct this deformity, but it is more practical to do a formal amputation of the deformed foot and fit an immediate prosthesis. Although there has been a limb fitter working at Soe from the Pusat Rehabilitasi Y akku,n (Yogyagkarta), he has now returned to Yogyakarta. This patient will either have to go to Ruteng to get a prosthesis or wait until a technician is trained and can work full-time in Soe. A very modest grant would go a long way towards training a technician in Y ogyakarta and this should be seen as an urgent priority.
This is a haemangioma of the finger.
The finger is a mass of inter-connected arteries and veins. A simple amputation of the terminal part of the finger is the only practical solution and can be done at any hospital. The Reconstructive Surgical Program attracts these patients who come because they want something done to relieve their disabilities.
It is hard to imagine how this young man has put up with such a deformity for so long. He is a farmer and sustained a severe burn to his forearm in his you•th. Following this, the hand contracted down into the forearm and two of his fingers actually became buried in his forearm. He has already had a series of operations to free the hand and still needs one more to stabilise his thumb.
Once again, this is the sort of operation that can be done at a peripheral hospital like Soe or Kefamenanu and is best tackled by the combined Australian / Indonesian team.
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A Nurse Anaesthetist (Pak Eben Liufeto ) and Operating Room Nurse (lbu Otta) working in So e Hospital.
Dr Charles W. Lay, working with the Australian / Indonesian Team at Kefamenanu Hospital in 1992.
This boy broke his leg but failed to get any treatment for it for more than a year.
By the time he had presented himself there was dead bone projecting from the shin.
First of all it had to be cleaned up and this was achieved by removing the dead bone under anaesthetic. He then dressed the wound daily with a strong salt solution.
Salt is very cheap and can be bought at any local store, but when dissolved in water will cleanse the dirtiest of ulcers. After 3 months' treatment with strong salt soltion, the wound healed and it was then possible to fix the bones with wires.
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This massive tumour was not a threat to life, but was certainly a nuisance and affected this woman's work. It turned out to be a simple fatty tumour (lipoma) and was easily removed at Kefamenanu hospital with a gratifying result.
present on this woman's back for some years. By the time she presented it was badly infected and was extremely offensive. It was treated with antibiotics donated by a Pharmaceutical firm and was removed under local anaesthesia in the Outpatients' Department of Soe Hospital.
Leprosy is still common in Timor.
There is a very good Y ayasan at Kefamenanu who care for leprosy patients and their relatives. Early diagnosis is essential if deformity is to be prevented and this is a good illustration of the importance of voluntary agencies in the overall control program.
Tinea and other skin conditions can easily be confused with leprosy and sometimes they co-exist.
The treatment of deformity in-leprosy motivates patients and leprosy workers to diagnose leprosy early before deformtiy has occurred. We see the Reconstructive Surgical Program as one way of opening the door to other Public Health initiatives.
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This tumour on the back of the head was quite benign but it was a deci·ded nuisance. This man had put up with it for many years before he was able to get anything done, mainly because he lived a long way from the hospital.
Neurofibromatosis, also called Von Rechlinghausen 's disease, is quite common. In this case it is nothing more than a nuisance but in some cases it has the potential for serious sequelae. These tumours were easily removed giving considerable relief.
A case of advanced Squamous cell Carcinoma of the face. This has progressed too far to treat. In any case, it would need intubation anaesthesia, which is not yet avaliable at the peripheral hospitals. Soe Hospital is presently upgrading facilities and in time it should be possible to tackle similar, but less advanced problems there.
This woman is blind in the right eye. The cause has not been deterrmined.
She wants the eye to be removed and replaced by an artificial eye. Neither this problem nor the one shown below have been tackled or solved so far. As the program evolves, hopefully both will be amenable to treatment.
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NORTHMED-The
Northern Territory Medical Overseas Aid Council was set up in 1991 and incorporated in 1992 specifically to address ways (including fund-raising) in which the Northern Territory and our near neighbours could co-operate in joint medical programs within the region. Current financial members are:V. Asche, Ph.D.
J. Beeby, R.N. CNS
D. Devanesen, MB.BS, MPH, FRACMA R. Draper, MB.BS
J. Fong, RN, CNS T. Giblin, MB.BS D.Gray,RN
J.C.Hargrave, MD, FRACS, DTM&H E.Jones,RN
E. Kettle, RN, Nurse-Midwife, FRCNA T. Nienhuys, Ph.D.
M Nowotny, MB.BS
M. Patel, MB.BCh., FRACP P. Thom, MB.BS, MPH B. Tynan, RN, Dip. Anthrop.
A Whyboume, MB.BS K. Rickart, RN, CNS D. Wheen, MB.BS, FRACS
ACKNOWLEDGEMENTS
We are indebted to the Office of the Minister for Health, the Cabinet of the Northern Territory Government, the staff of the Department of Health and Community Services and the Royal Darwin Hospital Management Board for their substantial help and enthusiasm in setting up and keeping this project running.
We are also indebted to the Hon. Sen. Gareth Evam for drawing our attention to significant sources of financial and professional help within AIDAB and the Australia Indonesia lmtitute.
The Australia Indonesia Imtitute has supported the project with generous grants for two successive years and has also been particularly helpful in areas of special expertise
In addition, we are most grateful to Smith and Nephew (Australia) Pty Ltd for a grant of $2500.
We intend to use this to recruit another surgeon into the program in 1993.
We would also like to thank the Darwin Rotary Club for the active role it has taken in providing funds to upgrade the Operating Room facilities in Soe Hospital, Timor.
The following companies have given us valuable support with medications and equipment, without which our task would have been virtually impossible:
1. Bayer Australia Ltd. (Ciproxin) 2. Ciba Geigy Australia Ltd. (Lampren) 3. Alphapharm (Flucloxacillin)
4. Merrell Dow Pharmaceuticals (Rifampicin) 5. Astra Phamaceuticals Pty Ltd. (Marcain) 6. Parke-Davis Pty Ltd (Ketamine)
7. Smith Kline Beecham (Flucloxacillin) 8. Eli Lilly Pty Ltd (Ke flex and Keflin) 9. Orthocare Pty Ltd (C-Wire Serter)
10.Johnson aJ).d Johnson (Sutures and dressings)