Facing backwards I see the past Our nation gained, our nation lost Our sovereignty gone All traded for the promise or progress What would they say What can we say Facing future I see hope Hope that we will survive Hope that we will prosper Hope that once again we will reap the blessing of this magical land For without hope I can not live Remember the past, but do not dwell there Face the future where all our hopes stand. (Iz. Kamakawiwo"ole)

Our Sanglah Hospital, one of the largest hospital in the province, and probably the largest in east part of Indonesia, despite all the critics and scorns, had to receive more than one hundred thirty patients and more than one hundred eighty bodies at one time at night on October 12, 2002. I always comment on this, that no hospital in the world would be ready to receive more than one hundred patients or bodies at one time.

At that night, nurses, doctors, surgeons were mobilized to work; medicines, medical equipments were concentrated at the emergency unit and activated, and we were one active team focusing to work. Through that night we did major surgery on 38 patients, especially for life saving surgery, exploratory laparotomy for bowel injury, for resuscitation; cleaned and derided the burn, and quickly evaluate and listed the patients condition, and more than a hundred patients underwent minor surgeries at the emergency unit. One patients passed away in the operating room, before the surgery was even begun, due to severe burn, and respiratory failure. Three more patient were dead on arrival.

Although, all foreign patients mostly Australian (119 patients?) were evacuated to Australia the next day (Sunday night), but most of them were already stabilized and undergone the primary surgeries.
Unfortunately, the communication between The Indonesian Medical Team and The Australian Medical/ Evacuation Team was not very well settled, that at our side, we did not have the time to register the complete names of all those patients, or to write down the patients diagnosis and problem before evacuation. But on the other hand, The Australian team never asked for medical reports, and never gave us some input concerning those patients. We had a bit of disagreement, concerning patient's stabilization before transporting.

The rest of the patients, mostly Indonesian were treated later on, for more definitive surgery by an International Team, consist of surgeons from Jakarta, Surabaya, Singapore, Thailand, The Philipines, Belgium, USA, (mostly plastic surgeons), who came later to help. Many patients
had to undergo multiple surgeries, for multistage tangential skin excision, skin grafting, internal fixation for fractures and for the removal of multiple foreign bodies.

The surgical ward (Melati Room) that night and the day after was converted completely into a burn unit, and more equipments were brought in immediately to give a better care for our burn patients. Funds, medicines, equipments were pouring in from International Medical Corp
(IMC), US-AID, International Red Cross, other countries and International medical communities to help us. Spontaneous volunteers came from different parts of Bali, BIWA organization, Expatriates living in Bali. We deeply appreciate for that. I feel without their help our work became very much harder, and depressing.

In general we had done our best with the facilities we had to treat those unfortunate patients.

Medical Training

Most Indonesian doctors were trained in The State or Private Medical School all over Indonesia. The training was divided into two parts.
First one is for 4 - 5 years, including the Basic Biological Sciences, Basic Medical Sciences, Para Clinical Sciences and Clinical Sciences.
The language of communication is Bahasa Indonesia. Most of the Medical Literatures are already translated into Bahasa Indonesia. The original English Medical Text Books are much more expensive and not always available. The second part of training program will take 2 years (internship), in which the medical students will rotated into different clinical department including surgery. The language of communication again is Bahasa Indonesia, and most of the text books are the same.

The further specialization (for example surgery) will take another 6 years. Again the language of communication is in Bahasa Indonesia.
Finishing the 6 years specialization (in surgery), and the further training to become consultant will take another 2 years.

There are a couple of adopted courses from USA, U.K, or Australia such as basic surgical Skill course, Advanced Trauma Life Support, Definitive Surgery for Trauma Care, USG for trauma, OSCA test, Care for Critically ill surgical patients given to the surgical residents (general surgeon)
in order to up grade their capability. There is some effort to nationally standardize our surgical training by giving the resident different level of board or national exams by appointed board examiner.

The medical education and the training program we have in Indonesia or Bali, are following the old Dutch System, with very little changes or improvements.

Looking at the training program above, it is understandable that the exposure of the medical students or residents to how is medicine and surgery are practiced in different world is very - very limited. They treated patients the way they were taught by their teachers and by our
standard. The English as the international language of communication especially the medical English, was learned in a very limited way and in very short time, and it had never been used broadly.

There is also some limitation in the using of new medical technologies, because of in-availability of those equipments in the hospitals where they were trained.

Another problem for the Indonesian medical doctors or surgeons is the lack of International standard for the medical education or training program and the lack of attachment to other professional organization from other countries. The surgical training is trying to fulfill the
national standard by having the same international courses for all surgical residents or general surgeons (the courses have been mentioned above), and having different level of national examination for the residents of surgery, but still there is no international standardization. This is probably the reason that the Indonesian doctors especially clinician will have so much difficulty to go abroad to study.
They can come and observe, but not hands on experience in treating patients.

Mechanism for Indonesian Clinicians to have the permission to study and to have the hands on experience in treating patients, should be developed, so that Indonesian Clinicians will have huge opportunity to study medicine/ surgery in the developed countries.

Health / Medical Services

The sanglah Hospital, as one of the largest hospital in the area, were standardized and equipped similar as other provincial level hospital in Indonesia, was taken by surprised that night by the arrival of hundreds of patients and bodies. Patients came from the booming site not in properly organized. The in-availability of pre - hospital care system for the field triage in Bali, added the problem of the patients selection and priorities.

The Trauma Centre at Sanglah hospital, which was just developed two years ago, with the idea, that the specialist or general surgeons committed to trauma should be in-charged 24 hours/ day at the trauma centre, and treating trauma and emergency surgical patients holistically and not fragmented. To whom, patients could always rely their trust and see the same face doctor who is responsible for their care. The Trauma team consisted of General Surgeons (as the leader), assisted by the Neuro-Surgeons; Orthopedic Surgeons, Anesthesiologist, Trauma Nurses,
Intensive Care Unit nurses, etc. The Trauma team would be helped by Team of Consultants from different field in surgery or medicines. The Peer Review Committee would function as a quality control, and always look into the surgical care given by the team and help to improve the medical/ surgical care.

At present, the existence of Trauma Centre was all the time criticized and questioned by sub-specialist in general surgery. They feel that their field have been invaded by the presence of general surgeons at the trauma center; but who actually in the past, was not able to provide a
holistic surgical care for injured patients. Trauma and Emergency Surgeries at that time, were very much fragmented, and were given with high morbidity and mortality rates. That is, because the care was actually given by different level/ years of surgical residents in-charged at the E.R, while the consultant stayed at home waiting for the phone call or giving order by phone only. Trauma and emergency surgeries were learned not from the senior surgeon, but from the older
surgical residents, which sometimes as we joked about it, we called it as learning the black magic surgeries (not learning the proper way). The Trauma Centre/ system in Bali, is the only one in Indonesia, recruiting general surgeons as the main core of the trauma team. This is quite appropriate if we are looking at the recommendation by the American College of Surgeons - Committee on Trauma.

So, we are actually going to the right direction, but we need further training and exposures of our surgeons to improve their skill, to expose them to the new medical/ surgical technologies, to observe how medicine or surgeries are practiced in the western world. They have to improve their English, to have a better confidence and to broaden their horizon.

At the time being the surgical care given at our hospital is quite cheap compared to other hospitals abroad. The insurance system is not yet very well established. Only small percentage of patients are covered by insurance policy, which is in my opinion in many of them are not very professional. It is very easy to be the member, but it is very difficult when it comes to claim the money. Very often hospital has problem in claiming the patient insurance, which takes months while small hospital will need cash money for their operation. Most patients will have to pay cash from their pockets, and this segment of the population are not able to pay much.

The hospital will have to face a dilemma, whether to develop a modern, expensive and high technology hospital an International Hospital?, or to provide primary medical,/ surgical care to the population with more limited economy or limited ability to pay their hospital bill (which is more than 60% of the population). As the biggest hospital in tourist area, many criticism had been launched to us regarding the facilities, the language barrier problem of nurses & doctors, the quality of the doctors, the bureaucracies. But they forgot to remember how cheap our hospital is (especially compared to the price of hotel room in Bali), compared to the hospital in western countries, how little is our doctors being paid (very little!), and how all the doctors have to open their private practice in the afternoon, out side of the office hour in order to earn extra money! (and consequently it will be a long hours of working time) for them, to be able to go abroad to learn, to attend conferences to broaden their horizon., and especially to buy books and medical journals. Please ask the government how much money is allocated for medical care or medical education?.

There is discussion regarding development of an International Hospital in Bali. First of all, there is a question about : "what is actually a International Hospital? Hospital with five star hotel rooms; modern, sophisticated and expensive medical equipments? Or it is a hospital with foreign doctors working, or with local doctors working, who could speak English, French, or German fluently. The other questions is, who will be the patients, the foreign tourist who visit Bali, the expatriates who
live in Bali, or the rich Balinese population? So where will the majority Balinese population be treated.

Looking at the amount of big five stars hotels in Bali or the foreign population (expatriates) who are living in Bali, definitely we need an International Standard Hospital. The question is, where this international standard hospital should be built?, so that everyone coming or living in Bali, expatriates or local Balinese will have a one best, standard (international) medical/ surgical care they can trust and they can afford. Good medical care or surgical care are very expensive, and probably too expensive for the most Balinese. Government or privately funded, or a cross subsidy International (?) hospital will have to be applied wisely for one standard best medical care in Bali.
Probably develop and built Sanglah Hospital to be one International standard hospital, is one of the many choices we have, as far as, it could fulfill certain conditions or changes.

Building an International Hospital separate from Sanglah will probably needed in the future, but that can wait until Sanglah Hospital has been comprehensively improved and modernized. So, we can minimize the image of double standard of medical/ surgical care to the different level of populations in Bali.

In terms of training program for the man-power (doctors, surgeons, nurses, Lab analysts/ technicians), which I think is the most crucial part of the improvement of Sanglah Hospital, especially the Trauma Centre/ The Trauma Team, which we expect will always be exposed to many foreign visitors or expatriates, and Balinese living in our island.

Training program could be conducted by inviting trauma surgeons, burns surgeons with a lot of experience working and teaching our local trauma surgeons, or by giving the opportunity to our trauma surgeons, burn/plastic surgeons, nurses etc to be trained abroad in big Trauma Centre in the western countries. This exposures or training program is quite important to the development of wise, experienced, skill full surgeons, and who supported by a good system, a well equipped hospital, and good staff.

The Pre-Hospital care and field triage has to be developed as well, this will need a good system, a good communication, because this program will involve a great deal of many other department, such as Police Department, The Army Hospital, Fire Department, Hospitals, Health-Centers, and Hotels. In the case of mass casualties like what happened on October 12, 2002, the readiness and the participation of this pre-hospital care/ Field Triage would probably save more lives. This is going to be the home work for us and the government to finish.

One of my ambition, that one day Sanglah Hospital, especially the Trauma Center and Emergency Surgery and Burn Unit will be the place for other surgeons from all over Indonesia or even other countries to come and to learn. We have all the patients for the training, but not the facilities and a good system.

Denpasar, November 18, 2002.

Dr.Tjakra W. Manuaba
Carlos Vinas Barmona