Taibesse, Timor-Leste

1st August 2015

I have found a beautiful house to rent, which is in the suburb of Taibesse.  It is within 2 km of the hospital heading south towards the hills.  It is one of a few houses in a Timorese family compound and has the most beautiful tropical garden which I know my kids will love.  It is only two bedrooms but has a day bed in the lounge which I will be able to sleep on when my mum is here.  My street is well known for its stretch of Banyan trees which give it a lovely tropical Asian feel.  I did not realise that the Banyan trees are actually fig trees and found all throughout Asia, the Pacific and even parts of Australia.  They have a characteristic aerial root system that become very thick and woody and trunk like.   There is also a Futsal pitch and football field (not much grass) across the road so on the weekends there is often an epic amount of people and cheering due to a local match.

I have started to walk to work along the canal which is very pleasant for about one km of it due to the lack of traffic.  Its lovely to walk down the road and be greeted with Bon dia in the morning and Botarde in the afternoon, its definitely something we don’t do in Australia.  Given that the large fresh food markets are just up the road in Taibesse, I am usually walking behind the local vendors that sell from door to door.  I am starting to recognise the same vendors, often with a huge array of local green vegetable and herbs.  Sometimes it is live chickens, sometimes fish including large and colourful coral trout.  Fair to say on these days I walk a little further behind them to avoid the smell. 

I continue to see interesting cases at work.  As expected in a tropical country, microbial keratitis (corneal infection) is very common and unfortunately often leads to irreversible vision loss and even blindness.  The burden of disease is exacerbated by multiple factors in Timor-Leste, many which are common to many resource poor environments.  These include delayed presentation, lack of adequate primary care and early referral systems as well as limitations in diagnostic services and access to topical antibiotics.   Additionally, a lot of our patients have come from the districts, or rural areas, of Timor-Leste and have often acquired the infection through trauma, particularly agricultural based trauma which in itself puts them at a higher risk of atypical infections such as fungal and amoebic infections.  Unfortunately we do not have access to a pathology service or the agents to do our own microscopic examination of corneal scrapes; essentially where we take a sample of the cells of the cornea and attempt to isolate the particularly bug.  This normally helps immensely with streamlining treatment and is the mainstay of diagnosis in the health services that I have worked in previously.  Unfortunately I have seen quite a few patients with severe microbial keratitis, both adults and children, who have gone blind from perforations or  large corneal scars.  Services such as acute corneal transplantation are not available in Timor-Leste.

On the weekends I have found a local coffee shop; Letefoho Specialty Coffee Roaster, down on Beach Rd, in the Hotel Royal Beach Building.  It is a little way from my house but definitely worth the drive.  The staff are super friendly and make a good range of strong (just the way I like it) espresso style coffee. I could easily while away an hour or two getting thoroughly caffeinated and eyeing off some Banana or Sweet Potato bread.  

Banyan Tree, Taibesse, Dili

Soccer pitch opposite my house in Taibesse

My local fish vendor

Severe microbial keratitis (staining yellow with fluorescein), unfortunately very common in Timor-Leste 

The wonderful, friendly staff at Letefoho Specialty Coffee Roasters, Dili, Timor-Leste

Dare, Timor-Leste

16th July 2016

Dili, Timor-Leste

I am settling into work slowly.  With the operating theatres out of action we have managed to configure an alternate makeshift theatre.  It was quite amazing to see a 24 hour transformation from a library/meeting room filled with bookcases and tables and chairs to a fully functioning theatre.  We have no running water or plumbing in the new theatre so scrubbing is done with sterile water into a large plastic lined rubbish bin.   We are however only booking patients with cataracts that are causing significant reversible blindness and most of our patients have vision that is ‘Count Fingers’ or ‘Hand Movements” , that is, they cannot even see the largest letter on the Snellen (eye) chart.   Surgical case numbers are significantly down at the moment anyway due to an overall decrease in the total number of patients presenting to the clinic. According to the clinic staff there are a lot of police roadblocks in the east of the country and people are simply not travelling around the country like they normally would.

From a clinical point of view I have already seen some very interesting cases.  I saw a case of Gyrate Atrophy on my 3rd day here of which I haven’t seen a case in 4 1/2 years of being a registrar.  I have also seen a patient with a large carotid-cavernous fistula - impressive in that there was a cephalic bruit and the biggest superior ophthalmic vein I have ever seen, almost the size of my little finger on CT scan.  We are lucky that the CT scanner is working at the moment as it is intermittently out of action.  Thankfully this patient was accepted to travel for neurosurgical intervention in Indonesia from the referral committee at the hospital.  This committee meets once a week and medical and surgical teams can present patients they feel would benefit from receiving treatment outside of Dili due to the service not being available in Timor-Leste.  This is normally in Surabaya, Indonesia but can also include Singapore if the case requires.   

I have been reading some books on Timor-Leste to try and understand a little more about the history of this small Island nation.  Currently I am reading Shirley Shackleton’s account of her husband Greg Shackleton who was one of the Balibo 5 journalist who was killed on 16th October 1975 in the early stages of the Indonesian invasion.   She then took up the fight for truth and justice  for the events surrounding the death of the five news and camera men and ultimately became involved in the Timorese resistance movement and long struggle for independence.

I have not ventured too far out of Dili yet this trip as I have largely been on my own but I did make the trip up to Dare on the weekend.  It is a small town in the Fatunaba hills around 10km south of Dili which houses a small war memorial, museum and cafe.  Many of the pictures are supplied by the Australian War Memorial and it is a beautiful setting to sit and contemplate and escape the heat of Dili.   It was originally built by the Australian Commandos of the 2/2 Independent Company who were present on the Island between 1941 and 1942 and waged a guerrilla style warfare against the Japanese, despite Portuguese Timor declaring its neutrality in WWII.  The Australian soldiers were greatly assisted by the local Timorese who were called Criados and many owed their lives and success of the campaign to these Timorese.  Unfortunately with the withdrawal of Australian troops, the Timorese suffered significant reprisals and it has been estimated that approximately   40 000 Timorese lost their lives in WWII.

The road further South of Dare heads up to Aileu and Maubisse and then on to Hatubuilico, which is the base for climbing Mt Ramelau.  I had visited Timor-Leste 10 years previously and at that time made the trek up the almost 2963metre high mountain.  At that time, we overnighted in Hatubuilico

and then had a 4am start to reach the summit for sunrise.  The views are spectacular with some low lying cloud and a vista to the north and south coasts.  I’m not sure if I will get the time to climb Ramelau again, especially once the kids come over but I am keen to try any other walking opportunities.

A very large Superior Ophthalmic Vein

The view from Dare, north towards Dili

The top of Mt Ramelau

 

Market Day In Hatubuilico

Dili, Timor-Leste

22nd June 2015

I have finally made it to Dili after much anticipation and preparation for the last 9 months since I received the Hobart Eye Surgeons/RANZCO eye foundation scholarship.  I have spent the first week living in a hotel in central Dili which thankfully is within walking distance of the hospital.  As with any major move I am feeling a little overwhelmed, particularly as I am still apart from family.    Much of the week has been consumed with administrative matters such as getting a sim card and internet access, finding suitable long term accommodation, thinking about what sort of vehicle I will need and of course finding out the best places to shop for food.   The supermarkets are amazingly well stocked with Australian and New Zealand products and the local fruit and vegetable vendors have a good supply of local products.  The papayas and pineapples thus far have been delicious.  There are multiple different varieties of local bananas as well although I need to find someone to share them all with me.

Accommodation can be tricky to find in Dili, especially if you need a few rooms for a family and are on a scholarship wage, which I obviously am.  The two and three bedroom houses that 

I have seen thus far have not really been suitable for my children so I hope that something comes up soon.  Obviously there are no real estate agents so trying to find accommodation is through word of mouth, assistance from the Royal Australasian College of Surgeons (RACS) and the online social media sites of Dili expats and Dili expat face books sites.

I am working at the National Eye Centre (NEC) which is a collaboration between Fred Hollows New Zealand and the Australian ATLASS II program, which is coordinated through RACS. It is on the site of the National Hospital or Guido Valadares National Hospital (GVNH), in Dili.  It has 4 individual consulting rooms and one large consulting room with 4-5 slit lamps in it for the registrars, myself and the international consultant.  We also have a diagnostic room with an A-scan and Keratometer (for measurements for cataract surgery), a field machine for screening for glaucoma and an IOL master for when we do phacoemulsification (mostly with visiting faculty).  We have two laser machines, an Argon for pan retinal photocoagulation for conditions such as diabetes and retinal vein occlusions and a ‘YAG’ for treating posterior capsular opacification.   All in all it is an amazing resource and service  for a relatively ‘new’ country like Timor-Leste. 

The NEC also has its own operating theatres for local anaesthetic cases, of which the main theatre has capacity for two tables to be utilised at once.  Unfortunately at the moment the theatres are out of commission as there is reportedly a problem with rising damp and the tiles underfoot are all ripped up.  We therefore have to use the main theatre block in the hospital if we wish to do any emergency cases.  We have a regular general anaesthetic list booked on Mondays if we require as well.

As with all my travels, finding some good running routes is always a priority.  During the week I have driven out to the Christo Rei statue and run up and down the  ~ 750m of stairs 3-4 times.  On the weekend I make the trek from town to Christo Rei and back which is a good 12km run. Getting an early start is crucial to avoid the worst of the heat and traffic.   The hills behind Dili look very inviting from a trail running point of view but I have been told not to run them on my own, even during the day.  Mountain biking is very big in Dili and I can certainly see why - there must be kilometres of serious trail in and around Dili.

Christ Rei Statue, Dili Timor-Leste

Looking East from Dili, towards Christo Rei

Our busy consulting room at the National Eye Centre

Kuala Lumpar

30th May 2015

Kuala Lumpur

I am in transit on the way home from Hyderabad and looking forward to the next part of my adventure this year.  On one hand I would have liked to have more ‘numbers’ under my belt before I arrive in East Timor but I also feel like I have gained enough skill to start doing SICS on my own.  I operated this morning and did three of my best cases so I have to apply that confidence when I start doing SICS surgery in Dili.  I have also meant lots of inspiring ophthalmologist, not only from India, but all over the wold, including Indonesia, Argentina, Nigeria and Vietnam.

As we had Friday’s off, yesterday I took an opportunity to do only my second real bit of sight seeing and took myself off to the Golkonda fort complex, built for the sultanate of the Qutb Shahi dynasty (1518 to 1687).   Temperatures again were quite unbearable so I left it as late as possible and took a taxi.  As far as I could tell I was the only international tourist there so I think I provided a bit of a spectacle for the locals.  After the walk through and up the fort it was a relief to get a bit of a breeze and also very nice to have an elevated view over Hyderabad to provide some geographical spectacle as to where I had spent the last 4 weeks.  Walking down with the sun setting was magical despite the heat.  

I had also previously made it to Hyderabad’s other major tourist attraction which is The Charminar, a 16th century monument and mosque.  The auto drive out there was pretty hot and dusty and the same to be said for walking around the market places at the base and surrounds of the The Charminar.  Unfortunately the area has a large concentration of beggars and people living of the street which is always confronting to see.  My companions from the hospital were keen on buying local fabric so I spent a lot of time sitting on the floor of fabric shops getting served tea! 

I think my favourite Indian dish from my four weeks living in India is Chana paneer and roti.  Chana paneer is basically a light curry of chickpeas and the famous Indian cottage cheese - paneer.    I could possibly eat it 3 times a day.  Another favourite which I had never had before this trip to India was the classic Southern Indian breakfast of Idli (fermented rice cakes) and the spicy sauce accompaniment called Sambar.  This was served every morning the hospital cafeteria along with a coconut chutney.  I even learnt to eat this somewhat messy meal (at least to a beginner like me) with my hands as is custom. 

Before heading to East Timor, I am spending 5 days with my family and extended family at Gunung Mulu National Park, a world heritage area in Sarawak, in Malaysia.  I’m looking forward to the tranquility and fresh air of the rainforest and of course seeing my nearest and dearest again.

https://en.wikipedia.org/wiki/Golkonda

 The Charminar

Me operating at LVPEI

The bird viewing platform in the beautiful rainforest of Gunung Mulu National Park, Malaysia

Hyderabad

14th May 2015

SICS training is going well.  We are expected to get through ~30 cases in the 4 weeks so we do roughly 1-2 cases per day.  We operate Monday to Thursday and then Saturdays.  I am certainly understanding the respect that needs to be given to a well constructed scleral tunnel.  The fellows make it look so easy but it is far from easy.  As with all cataract surgery, each step is as important the next and small errors early in the operation can impact significantly on subsequent steps and ultimately the success of the operation.  The other concept I have struggled with is the need for a large as possible, but intact, capsulorhexis (peeling the capsule of the cataract - akin to peeling the skin of a grape).  As a phaco trained surgeon I have struggled to expand my ‘rhexis’ and at times have had to place relaxing incisions to ensure prolapse of the nucleus does not place undue stress on the capsule and cause a subsequent posterior capsular tear.  

Our patients are all from surrounding villages and towns to Hyderabad.  The hospital has a very good system for these patient in that they are asked to come the day before to check any medical and ocular co-morbidities and ultimately final fitness for surgery.  They are then given free accommodation and board for the night.  They are then bused to the operating theatre, and all return later in the day once everyone has had their surgery where they are then given another nights free accommodation and food.  The following day we see then post-operatively and they are then given the all clear to go home with strict counselling for drop usage and general care of their eye after surgery.  The LVPEI motto is “so that all may see” certainly fits with their ethos of providing free cataract surgery for those who could not afford it otherwise.

As an aside, the states of Telangana and Andhra Pradesh are currently going through intense heatwave.  Everyone has been telling me that May is the hottest month for Hyderabad and that the rest of the year has a relatively pleasant climate!  Daily temperatures are 47 degrees .  Thankfully we spend the worst part of the day indoors in air conditioning but the heat is making going outside unbearable.Unfortunately there have been reports of approximately 2000 people dying, possibly more, from the heat across the two states which is tragic.  

I have been trying to do an early morning walk/run in the nearby K.B.R National Park (only a 4 km circuit) for some respite from the traffic and pollution.  Even at 6am in the morning the heat is intense but I am grateful for the 40 minutes of exercise.  I can definitely see the importance of green spaces for busy and crowded cities.  With the reddish dry earth and birdlife, on certain parts of the path if I can almost pretend I am in the middle of no where - the African veld, northern Australia -anywhere but downtown Hyderbad! As an aside my running gear is certainly different to what I wear in Australia with long pantaloon pants and a mid length Kurta and running shoes now my running gear of choice.

Click Here to watch Small Incision Cataract Surgery

The Life Saver - K.B.R National Park Banjara Hills, Hyderabad

My Choice of Running Gear in 47 degrees!

Click here to read more of the devastating 2015 heat wave in central India

www.abc.net.au/news/2015-05-30/india-reels...heatwave.../6509482

Hyderabad, India

3rd May 2015

Small Incision Cataract Surgery

I have started this personal and professional adventure with a month long Small Incision Cataract Surgery (SICS) course in Hyderabad at the L.V Prasad Eye Institute (LVPEI).  These courses are run for national and international faculty to expand their surgical skills.   I have completed 4 and a half years (out of 5) of ophthalmology residency in Australia and have trained solely in the phacoemulsification technique of cataract surgery so I am looking forward to learning a new technique and exposure to the excellent surgeons and trainers at LVPEI.  SICS was developed to provide a rapid, safe and cost-effective cataract service and is largely used in the developing world and resource poor environments.  Its equipment requirements are far less than phacoemulsification, requiring just a microscope, or simply surgical loupes in some instances.   It is the technique that I will be performing for the subsequent 6 months in Timor Leste (East Timor) as the fellow with the East Timor Eye Program

Hyderabad is located in Andhra Pradesh state in central India and is an easy one stop flight from Australia to Singapore and then directly to Hyderabad.  It is by no means on the tourist trail compared to other cities in India but I was looking forward to getting to know the locals as well as the Hyderabadi food.  I’d happily eat famous Hyderabad Biryani, a mixed rice rice dish, every day!  

I have travelled to India previously but still found arriving an assault on the senses.  The traffic, pollution, poverty and density of population can at times be overwhelming but I have also found beauty in the Indian people, their joie de vivre and the vibrancy and colour with which life is lived.  

My home for the next 4 weeks is the international hostel located at LVPEI at the Banjara Hills campus. Thankfully a cool and quiet refuge and very comfortable lodgings consisting of a private room and bathroom and communal living area, located above the clinical and surgical sections of the hospital  The walls of LVPEI are adorned with beautiful examples of Indian art and the hostel was no exception.  The canteen at the hospital provided 3 meals a day for very low cost and there was additional external restaurants across the (very busy) road.

LVPEI is a prestigious and international renewed eye hospital established in 1987 with rigorous residency and fellowship programs. Most residents and fellows do a 12 hour + day for six days a week.  The morning starts at 7 with clinical teaching in the main auditorium and this often split into subspecialty departments.  There are very fast internet linkups with the other LVPEI campuses and occasionally international speakers.  

There are 2-3 doctors doing the one month long SICS training course at any one time.  The trainees are a mix of paying individuals such as myself as well as local residents and international fellows.  The training courses start at the beginning of each month and continue for 30 days.  We are required to assess our preoperative patients the night before surgery as well as our postoperative patients the following day after teaching.  The surgical training itself was not in the Banjara Hills campus but rather at a day surgery in the city which reached by ‘auto’ for between 50 -100 Indian Rupees.  During surgery we were assisted by a different fellow each day which was extremely valuable in terms of picking up different approaches and ‘tricks of the trade’ of SICS.  I was so impressed by their surgical standards as most fellows were trained in extracapsular cataract surgery (ECCE), SICS and phacoemulsifcation and had done roughly 1500-2000 cataract operations  after 3 years of residency and 12-18 months of fellowship.  It certainly reinforces the fact that nothing beats numbers in terms of experience in cataract surgery.  By comparison a registrar (resident) in Australia can expect to have completed 300-500 after 4-5 years of training.

www.lvpei.org