Eastern Cape Paediatric Surgical Service
Annual Report 1999
Introduction
The Eastern Cape Paediatric Surgical Service based at the Frere and Cecilia Makiwane hospitals has been in operation since the first of February 1995.
This report highlights the activities of the fifth year of the service, a year in which we have endeavoured to continue to maintain a high standard of clinical care and practice.
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Contents of Annual Report 1999
Statistics of the years 1995 to 1999
Staffing - Medical Staff and Ancillary Staff
Rationalisation of Services and Infrastructure
Academic Meetings - Postgraduate Training - Teaching
Visits to the Department - Acknowledgements
1995 |
1996 |
1997 |
1998 |
1999 |
|
Admissions |
91 |
123 |
168 |
183 |
176 |
Neonates |
|||||
Infants and Children |
359 |
410 |
526 |
540 |
544 |
Total |
450 |
533 |
594 |
723 |
720 |
Operations |
442 |
521 |
658 |
686 |
677 |
Ventilator Days |
93 |
238 |
281 |
292 |
288 |
ICU Days |
504 |
807 |
910 |
972 |
960 |
TPN Days |
320 |
348 |
426 |
444 |
452 |
Deaths |
|||||
Postoperative Deaths |
7 |
9 |
9 |
14 |
13 |
Other Deaths |
13 |
5 |
13 |
14 |
16 |
Total |
20 |
14 |
22 |
28 |
29 |
Patients
Patients have been referred to our service both from within the normal drainage area of the central region of the province and increasingly also from the further reaches of the Eastern Cape; from Port Elizabeth, Uitenhage, Cradock, Graaff Reinet, Aliwal North, Jamestown, Barkley East, Elliot, Maclear and to the north of Umtata.
With the establishment of a Paediatric service at Queenstown, a great number of appropriately referred patients are now being referred from the northern region of the province.
In principle, our service has been limited to the care of children under the age of 3 years. In addition, at both hospitals, we attend to older children referred by our specialist colleagues in Paediatrics and Surgery. In particular, this includes some of the more complex Paediatric Surgical conditions occurring in older children such as patients with childhood malignancies.
With the availability of beds and theatre time at Cecilia Makiwane, most of our patients are handled at this hospital. However, with few exceptions, neonatal surgery is done at the Frere Hospital, which has the availability of a consultant anaesthetic service and high quality intensive care nursing.
The spectrum of conditions which are attended to include the full range of neonatal surgical conditions including oesophageal, intestinal and biliary atresia, neonatal midgut volvulus, Hirschsprungs disease, ano-rectal abnormalities, abdominal wall defects, spina bifida and allied conditions including hydrocephalus and encephalocoele, and a wide variety of urinary tract abnormalities. In addition, older children with burns, abdominal and bone and joint tuberculosis, hypospadias, ambiguous genitalia, neurogenic bladder and bowel, and patients with childhood malignancies form an important part of our practice.
The medical staffing of the Department of Paediatric Surgery, which improved considerably during 1998, has been maintained during 1999.
Dr. Piet Koeppen, a German surgeon, who joined our staff in November 1997 under the auspices of Centrum für Internationale Migration und Entwicklung, and Dr. Milind Chitnis, who rejoined our staff in September 1998 are two outstanding colleagues who have continued to provide first class care to our patients and have been excellent role models for the junior staff.
Drs. Tarina van Heerden, Mary Mathai and Vettivelu Coomaran each spent six months as medical officers in the Department. Each in his or her own way made valuable contributions and learnt a great deal about patient care as did Drs. C. Yako, P. Mbandazayo, S. Mbilase, T. Engel, M. Titus and H. Bardwell who as interns spent two months each attached to the service.
Dr. Neil Comley, a specialist General Surgeon, has relieved some of the pressure of our after hours work and is a valuable asset to the Department.
I would like to pay particular tribute to my staff. Their dedication to patient care is of the highest order. In the nature of our work, it is the consistent close attention to detail in the operating theatre and in particular the ICU, which permits infants with major abnormalities to survive and subsequently to prosper. This inevitably entails extremely long hours on duty both at night and over weekends. Our staff continues to do that at the expense of personal and family time.
Ancillary Staff
As a discipline, paediatric surgery is one, which requires the combined skills of a great number of people from across the spectrum of the health caring professions who have both knowledge and expertise in the management of children with surgical diseases.
The value therefore, of the assistance given by colleagues of the Paediatric Departments of both hospitals, cannot be overemphasized, nor the professional and high quality skill displayed by the specialist anaesthetists employed on a fee for service basis at Frere as well as the colleagues of CMH who are responsible for our lists.
I wish to record my appreciation to the many members of the nursing staff of wards, theatres and clinics at both hospitals who continue to provide high quality care to the children under their care.
In particular, I would like to express my appreciation to the nursing staff of the ICU of the Frere Hospital. The quality of their patient care is of an exceptional standard and is a cornerstone on which the Paediatric Surgical service has been able to develop and grow.
The staff of the Clinical Pharmacology department at Cecilia Makiwane and of the pharmacies, physiotherapy, imaging services and laboratories of both hospitals play key roles in our work.
The current situation which has patients being managed in two separate facilities geographically widely separated from one another is less than ideal as this means that a great deal of time is spent by staff members moving from one hospital to another. However, as children will inevitably continue to be managed at both hospitals, it is necessary that a paediatric surgical service be present at both institutions.
In order both to expedite and to provide the most effective service to our patients, many patients are transferred from Frere to CMH and vice versa as the availability of operating time and beds dictate.
It is appropriate that neonatal and other complex surgery be done at only one of the hospitals where the expertise for peri-operative care exists. The availability of high quality consultant paediatric anaesthetic cover, high quality nursing care available in the ICU and the proximity of Frere to the homes of the paediatric surgical staff for after hour calls has made the Frere part of the Complex the base for this demanding form of patient care.
On the other hand, the vast majority of routine paediatric surgery, in particular the work with older children is done safely at Cecilia Makiwane and many patients are moved from Frere to CMH for this purpose.
The restructuring of the Paediatric Department of both limbs of the East London Hospital Complex into a single unit has impacted very positively on the Paediatric Surgical Service.
Facilities and Infrastructure
The facilities and infrastructure of the two hospitals are in general of a sufficiently high standard for the conduct of a safe Paediatric Surgery practice. Many of the deficiencies, which had existed, have been addressed in order to ensure safe practice.
The five work stations consisting of open incubators, neonatal ventilators, monitors, infusion pumps and syringe drivers, for the Frere Paediatric ICU, purchased in 1996, has been of invaluable assistance. This unit is now certainly an excellent well-equipped facility.
Paediatric bronchoscopy, oesophagoscopy and cystoscopy equipment purchased in 1996 and 1997 continues to be of great value.
Official handover of paediatric gastroscope and fine instruments. |
The provision this year by the Centrum für Internationale Migration und Entwicklung of a Paediatric gastroscope and certain fine paediatric surgical instruments have allowed us to expand the scope of our service. (see photo) |
Operating Lists
The service has two formal operating lists at CMH and one at the Frere. Most of the neonatal work is of an emergency nature and of necessity needs to be done outside of normal hours and normal lists.
Outpatient Clinics
A weekly outpatient clinic is run at each of the hospitals; on Tuesday afternoons at CMH and on Wednesday afternoons at Frere.
Paediatric Oncology
The combined weekly ward round of the children with solid tumor malignancies by staff of the departments of radiation oncology, paediatrics and paediatric surgery has continued this year. This critical area of communication and decision making has opened the way for an improvement in the quality of care provided these patients.
The appointment to the Department of Paediatrics of an experienced Paediatric Oncologist, Dr. Sidney Smith to lead the Paediatric Oncology Service is a major milestone in the care of children with childhood malignancies in our Province.
Visits to Outlying Hospitals
Dr. Piet Koeppen has been able to make a monthly visit to the Paediatric Department of the Frontier Hospital in Queenstown. Through these visits he has been able to provide both clinical and academic support to the paediatricians who are doing such valuable work at this hospital. This has permitted the running of monthly clinics at the Frontier thus decreasing the number of patients needing to be sent down to our clinic in East London for follow up. This valuable service will continue into the coming year.
Academic Meetings - Postgraduate Training - Teaching
A weekly formal clinical meeting each Tuesday and two teaching "grand rounds" (on Tuesday and Friday) form the basis of the Department's in-service training programme. The Health Profession's Council for the acquisition of CPD Points has accredited all.
Teaching
Teaching of post-basic nursing courses and participating in the regular surgical and paediatric hospital meetings remains an important part of our work.
Library Services and East London Health Resource Centre
The Paediatric Surgery library has continued to develop during this year. A good selection of core paediatric surgical texts is now available, as are an extensive array of articles in subject file derived from the paediatric surgery literature.
Three of the major paediatric surgical journals are now available, as are a number of journals in ancillary disciplines such as paediatrics, general surgery and paediatric urology.
CD-ROM access to Medline as well as Internet access is available through the departmental computers.
All of our major textbooks and journal holding were transferred from the departmental library to the East London Health Resource Centre in 1998 where they are available to a wider audience. The Resource Centre with its conference facilities and library of print and electronic media is playing a very positive role in providing the academic infrastructure for the work of the Paediatric Surgical Service.
Database and Research
Records of all patients admitted under the care of the Paediatric Surgical Service are recorded in a database on the departmental computer. This provides a ready reference for information about individual patients; statistics of work done and will be a valuable tool in determining results of management in the future.
We see it as important to actively pursue research interests, as it is clear that there is a wealth of clinical material available for study from among our patients. Furthermore, there are some paediatric surgical conditions which occur more commonly in our region than in others and which are ill understood both in terms of their aetiology and their optimum therapy and on which it may be possible to shed some light in the fullness of time.
Once again, through the good offices of the
Centrum für Internationale Migration und Entwicklung, we have been able to obtain a digital camera for the work of our Unit and two computer printers. The digital camera now allows us to take clinical photographs and immediately incorporate them in to material being produced both for publication and for teaching purposes.
Publications
The use of intravenous infusion bags for the staged closure of abdominal wall defects in developing countries. "Chitnis M, Chowdhary SK, Lazarus C.
Indian Journal of Surgery 61(1) 26-29 Feb 1999.
Application of Malone Antegrade Continence Enema Principle in Degenerative Leicomyopathy." Chitnis M, Chowdhary SK, Lazarus C.
Accepted for publication by Paediatric Surgery International.
Congresses/Courses Attended and Papers Presented
Lazarus C: Presented paper: "Gastro-oesophageal reflux: Results of Fundoplication in infancy" on behalf of Lazarus C, Van Riijswijk E, Millar AJW, Rode H., Cywes S at the Third European Congress of Paediatric Surgery, Brussels, Belgium, May 1999.
Chitnis M: Presented paper: "Use of plastic intravenous infusion bags for the staged closure of abdominal wall defects" on behalf of Chitnis M, Koeppen P, and Lazarus C at the UNITRA Health Sciences Annual Research Day in Umtata, March 1999.
Chitnis M: Presented poster: "Use of buccal mucosa for hypospadias repair" on behalf of Chitnis M, Koeppen P, and Lazarus C at the UNITRA Health Sciences Annual Research Day in Umtata, March 1999.
Koeppen P: Presented poster: "Congenital tubular duplication of the oesophagus in a newborn presenting as oesophageal atresia" on behalf of Koeppen P, Chitnis M and Lazarus C at UNITRA Health Sciences Annual Research Day in Umtata, March 1999.
Postgraduate Training in Paediatric Surgery
A formal application through the Department of Paediatric Surgery at the Red Cross Children's Hospital and the University of Cape Town to the Interim National Medical and Dental Council for the approval of satellite status and the training of paediatric surgeons in this Department, was accepted by the Specialist Committee of the Council in 1997.
However, as paediatric surgery is a sub-speciality and sub-speciality training in a satellite department has not previously been accepted by the Medical Council, the Council regulations are currently being amended to cater for this need. This is awaiting the promulgation of the Health Professionals Council Regulations by parliament. This would have meant that our unit will become the first satellite centre in South Africa where postgraduate training in a sub-specialty would have been recognised by the Health Professionals Council.
In the interim however, as with a number of other Departments of the East London Hospital Complex, full teaching hospital status for a period of one year has been recommended by the relevant Committee of the Health Professions Council. This is as part of the Postgraduate Teaching Platform of the UNITRA in terms of a joint agreement involving UNITRA, the University of Cape Town and the Department of Health of the Eastern Cape. The training of registrars in paediatric surgery in the East London Hospital Complex will therefore commence in the year 2000.
Professor Larry Hadley, Head of the Department of Paediatric Surgery at the University of Natal and current President of the South African Association of Paediatric Surgeons; Professor Mike Davies, Head of the Department of Paediatric Surgery at the University of the Witwatersrand and Editor of the SA Journal of Surgery; Professor Alistair Millar, Associate Professor of Paediatric Surgery at the Red Cross Children's Hospital and Dr. Larry Jee, a Paediatric Urologist attached to the Red Cross Children's Hospital all visited our Unit this year. Each visitor conducted teaching ward rounds at both Frere and Cecilia Makiwane and in addition lectured to our Department and to colleagues of the Departments of Surgery, Paediatrics and Urology.
The visits have not only provided an opportunity of academic interchange but have allowed us to discuss aspects of the diagnosis and management of difficult clinical problems thus assisting in the care of these patients.
Acknowledgment
I would like once again to express my appreciation to many people whose encouragement has meant a great deal to the continued development of this service; to the MEC for Health, the Permanent Secretary and members of his senior staff in the Provincial Government; to the Medical Superintendents of the Frere and Cecilia Makiwane Hospitals; and to the many medical, nursing, paramedical and administrative colleagues of the two hospitals.
I would also wish to record my appreciation to Professors H Rode and A Millar of the Red Cross Children's Hospital whose advice on the management of difficult problems and constant support and encouragement means so much to us.
It is appropriate, also, to acknowledge the part played by
the Centrum für Internationale Migration und Entwicklung (CIM) to the development of an improved quality of paediatric surgical care available to patients in the Eastern Cape. CIM has placed Dr. Koeppen in our Department for the past two years and as has been mentioned in the report, have provided the Department with equipment to assist us in our work. I wish to express my very sincere personal appreciation to the CIM to this very significant contribution.
Colin Lazarus, Principal Paediatric Surgeon
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