Monday, October 24, 2016

Jakarta, Indonesia

By: Craig R. Louer, MD
September 18 - October 1
I was fortunate to travel to Jakarta, Indonesia for my international rotation. To give some background on the region: the city of Jakarta contains over 10 million inhabitants, which is larger than any US city. The entire metropolitan area is estimated to contain more than 30 million people, making it one of the largest cities in the world, second only to Tokyo, Japan.  The country, itself, is likewise impressive: it is made up of over 13,000 islands of varying sizes located both north and south of the equator. Indonesia spans over 3000 miles in its east-west direction, more expansive than the contiguous United States. It is the 7th largest country in the world in terms of combined sea and land area. I was surprised by the scale of Indonesia as it is a country that I knew little about and do not hear mentioned much in global news and events. I was most impressed with the ethnic diversity of Indonesia: many of the islands have their own separate races, cultures, languages, customs, religions due to developing in relative isolation prior to Dutch colonization. The Republic of Indonesia was established after liberation from Japanese occupation by the Allies after World War II.

The front entrance of RSCM, the final tertiary
referral center for Jakarta.
My  faculty hosts for the rotation were Dr. Aryadi and Dr. Ugok, two pediatric orthopedic surgeons who are friends of our Dr. Dobbs, who has spoken there a number of times.  I rotated mainly at RSCM hospital, which is the largest and highest-ranking referral center in Indonesia.  Most of the cases seen at this hospital were referred from other centers due to complexity or because they had already treated and had a complication, so in many ways this was analogous to Barnes-Jewish Hospital. My other hosts for the trip were the wonderful residents who I interacted with. The residents assigned to the pediatrics rotation during my time were Dr. Adrian (5th year), Dr. Juno (4th year), Drs. Aji and Rizqi (3rd years) and various “Orthopedic Basics” (or interns), who seemed to help in casting clinics and ORs on a rotating basis, thus they were different each day. The hierarchy of academic medicine is even more pronounced in Jakarta than what we are used to in the US system: no request from an attending is taken lightly or deemed too arduous. The third year residents, at the attendings’ request, served as my personal liaisons to the city and hospital: picking me up from the airport in the middle of the night, taking me to the grocery store, often taking me to the hospital and restaurants and anywhere else I needed to go around the city, regardless of their personal schedules and responsibilities.  At times, I felt like a burden to them because I can’t imagine constantly taking care of a visitor along with my responsibilities as a resident, however I came to realize that that level of service is part of their culture, and they looked at it as an honor to have me there as their guest. 

The Children’s hospital on the RSCM complex.
This beautiful building had been built for years,
but was still unused due to lack of funds to be able to
furnish with appropriate equipment.
Our day-to-day schedule was actually fairly slow-moving, and this is a result of the low operative volume. There are many systemic, bureaucratic, and economic reasons for this, but Dr. Aryadi is only allowed one OR room per week (Wednesdays) at RSCM.  Because of this, Dr. Aryadi also works at a private hospital where he has private clinics and ORs to fill his time.  There are only 900 orthopedists in a country of about 255 millions. Only 10 are pediatric-trained, and only 7 of these are very active.  General orthopedists typically try to deal with pediatric problems on the local level as much as possible, and refer to RSCM only when necessary. I was able to accompany Dr. Aryadi to his private clinic (RSCM Kencana or “gold”), and found that his patient encounters there were very similar to those I have seen at our hospitals here in terms of acuity, timing, patient interactions, and resources.  The public clinic, however, had many eye-opening differences from what I was accustomed to.  Clinic volume was high, and there was a high-yield of operative cases seen, but most are put on the waiting list, which can be over a year for elective cases! Access to care is certainly one of the larger problems facing Indonesian healthcare. There are also cultural barriers to seeking care, as many patients are fearful of physicians, and specifically of having metal implants in their body that are thought to be unnatural and maybe will conduct electricity and cause harm. Due to these fears, many patients with traumatic injuries will visit “bone-setters” who will massage fractures and place in a cast made from gauze dipped in an egg/honey mixture. This is probably adequate for fractures that don’t need internal fixation, but they have limited knowledge of medicine and complications, so many of these injuries are mistreated and neurovascular complications are created or go unrecognized until too late. 

Interesting Differences in Hospital Care
Outpatient clinics were conducted in the generic “surgical” clinic that has 3 exam rooms. Pediatric orthopedics only had one of the rooms twice per week, but we move the patients quickly! Patients come from far and wide, sometimes traveling for days to make their appointment. By the time we showed up to clinic, the waiting room was already full. They were seen on a first-come, first-serve basis. The patient, family, me, and generally all of the residents would be in the small room together.  Patients carry all their films around with them. We would generally look at films, examine the patient, then quickly come up with a plan and tell the family what we would do. These problems generally were not subtle, so there was not much time spent outlining their symptoms with a history. I don’t believe I ever saw a patient ask a question or challenge our plan of care as is commonplace in the US. Generally speaking, they were just so grateful to see a doctor they accept a very paternalistic medical model.

National healthcare means that all patients can get healthcare sponsored by the government, but it is not near the standard we are used to. You have waiting lists for everything. Furthermore, the government insurance must approve studies and surgeries, including implants, and they generally will not pay for advanced implants beyond uni-planar external fixators and simple plates for trauma.

The hospital itself was fairly modern, albeit very different. It has some air-conditioned spaces, usually department offices, otherwise the hospital and wards are ambient temperature, which is generally 90-100ºF. Outdoor corridors link different parts of the hospital and separate buildings.  Jakarta is in the tropics (just south of the equator), thus it is always hot and humid, but it varies whether rainy or dry season. The physicians generally all wear short-sleeved shirts and white coats.  Many of the residents wore tennis shoes. The hospital has only 2 rooms for adult orthopedic patients: 6 male patients in one room, 6 female patients in the other.  Patients are often admitted a few days prior to their surgery to complete the workup and because they usually traveled from afar. The surgeons cannot perform elective surgeries requiring an inpatient stay if their census is full. In cases where they are at capacity, the consultant surgeons will have to get together and vote on which patients get to stay and get their treatment (Like SURVIVOR, RSCM edition).

The residents train for 6 years of medical school, which starts post-high school. Residency is 5 years long. They qualify for residency based off a written exam demonstrating aptitude for Orthopedic surgery, as well as interviews, similar to our application process. There are about 16 residents per year, meaning about 80 residents total! That said, there were only 10 “consultants” or attendings at RSCM, and many have appointments at private hospitals where the residents do not rotate, so there is significantly less clinical volume than what we see in our training at Washington University. When they are on-call overnight, they typically see 2-3 consults per night. However, they must do everything for the patients, be it perform blood draws, position for Xrays, various admission paperwork. If the patient needs surgery, the resident must fill out the insurance application for surgery as well as track down the implants that would be necessary and take them to processing to be sterilized. They do not have “standard trays” for cases and each case I saw had individual implants that we looked at the day before and then was subsequently peel-packed. If you did not think about a certain instrument or implant prior to the operating room, it will not be available for you. Don’t drop things either!

In the operating theatre with the Pediatrics Residents
after placing a post-op splint.
After walking outside to get to the separate Operating Theatre building (or OT, as they call it), I trade my ID badge for a set of scrubs and a key.  In the locker room, I was instructed to remove my shoes AND SOCKS and put on the community shoes, which were different varieties of rubber crocs that probably were not washed. Surgical mask goes up even in hallways outside ORs, cannot take down until out of the corridors. No phones allowed (theoretically, but every resident smuggled theirs in and taught me to do the same). Gowns were cloth and reusable, so had to wear a plastic, impermeable butcher’s apron below gown to keep dry. If feet get bloody during case, then wash your feet in the shower as soon as you leave OR and change crocs. Prep, drape, and timeout are pretty consistent to our norms, but prior to incision they also pray for health of patient. One of the surgeons, (usually the resident who will be primary surgeon), says a prayer and everyone is silent for a few seconds.

On Friday, they have an academic day. The morning is about 4 hours of case presentations/conference where every case from each service is discussed with a few consultants present to add commentary or ask questions.  There usually were only a handful of cases to discuss from each service for the week, including overnight call cases (most trauma is handled in the regional/non-referral centers). Because of the low-volume, there was a significant focus on in-depth presentations and full discussions so each resident present could hopefully learn something even if they were not present in the cases.  They take huge numbers of clinical photos for each case in order to have a good presentation for this conference, they mentioned the goal is to have each case to have pictures such that it could be published as a case-report, if desired. After conference, they have residency-wide prayer for the muslim residents.  Hindus and Christians are typically then done for the day.

Interesting Cases
Case 1: High left hip dislocation in DDH.  Countless children were seen with chronic dislocations.  They would still need to wait on the ~1year surgery waiting list.    
Case 1

Case 2:
Forearm nonunion.  Common problem due to cultural barriers and access to care.
Case 2

Interesting Experiences Outside Hospital
My  host residents enjoyed taking me out to eat for some traditional Indonesian Cuisine. Some highlights (and lowlights) included Rendang, which is traditional Sumatran way of preparing/cooking beef, which involves a BBQ-like braise and slow-cooking. This was delicious, but a little spicy.  Some items that I tried but did not enjoy as much were fried chicken feet and cow cartilage. The majority of meals (including breakfast) were slight variations upon the staple foods of fried rice, chicken, fish, and few vegetables.

The traffic in Jakarta is stifling, due to the population density and congestion. Many people ride motorbikes to weave in and out of traffic to speed up their commute, and this leads to many patients in orthopedic clinics. There are many helpful citizens posing as “police” who will (for a small fee) stop traffic to help you cross the street, make a turn in traffic, or park amidst the chaos of typical.  When the real police show up, these guys go running.

Two of the residents were kind enough to invite me to play basketball at their weekly game with other surgery residents on Friday night around 10pm. Basketball is 2nd most popular sport to watch/play second to football (soccer).

Saturday morning soccer practice after our scrimmage;
I loved the department-provided jerseys, very official!
On Saturday morning we went to soccer practice with the department. They have a large (>22 player) soccer team made of only orthopedic surgery residents.  They have official jerseys, equipment, and even a paid coach from a local gym/athletic center. The sports practices are mandatory for interns, with the goal of building muscle and camaraderie on Saturday mornings. If you miss practice, it is analogous to not showing up to the hospital on a workday, and you will receive extra call shifts. We did drills for about an hour, then played a full 11-on-11 soccer scrimmage. The interns are responsible for providing the equipment and jerseys, making sure it is all laundered.

Summary of Experience/Overall Impressions
Visiting Indonesia was a great experience, and one that I am very grateful for. Due to cultural and economic influences, I encountered many problems and challenges that are unique to the region that I had not previous seen in my training. Often, their resources to deal with these problems were limited, and treatment approaches differed accordingly. Despite these differences, I saw that the surgeons discussed problems, biology, and treatment principles in ways similar to our surgeons at Washington University, and they were always trying to do the best they could for their patients. I found Indonesian culture to be charming and interesting, and the people themselves were beyond hospitable and kind. I have left my international trip with many great memories, knowledge of some new and rare problems, gratitude for the seemingly limitless resources that we enjoy at our institutions, and most-of-all, an appreciation of the common mission that we all share as orthopedic surgeons. 

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