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Report January 2023

REPORT ON ACTIVITIES OF WORKING HANDS: JANUARY 2023

Note: Covid imposed a gap in our visits: the last visit, pre-Covid, was in January 2020.  The visits have now resumed: January 2023

Working/Teaching trip organised January 2023, to:

Lalgadh Leprosy Hospital, Janatpur

Green Pastures Hospital, Pokhara

Kirtipur Hospital, Kathmandu

Activity:

  • Teaching and tutoring of numerous surgeons and other personnel in all three venues; Instructional Course in Kirtipur, Kathmandu
  • Teaching and organisation of Hand Therapy services in Lalgadh and Green Pastures
  • Teaching and organisation of nursing services in theatre, Lalgadh and Green Pastures
  • Team: 7 personnel
  • Delivery of some 100kg of kit, instruments, crutches and aids, consumables

7th to 30th January 2023

Periods spent in the three hospitals:

1st period: Lalgadh Leprosy Hospital, Janatpur: 8th to 17th January 

2nd period: Green Pastures Hospital, Pokhara: 18th to 23rd January

3rd week: Kirtipur Hospital, Kathmandu: 24th to 30th January

  • Team: 

Surgeons: Davina Cavallaro (DC), Plastic Surgeon, Salisbury

Donald Sammut (DS), Hand Surgeon, Bath and London

Francesca Susini (FS), Hand Surgeon, Milan

(Sam Gidwani, Surgeon, part of our core team, withdrew close to the departure date for personal reasons).

Anaesthetist: James Rogers (JR), Consultant Anaesthetist, Bristol

Theatre Nurse: Karl Davies (KD), Operating Department, Bath

Hand Therapists: Jean Cahill/O’Reilly (JC), Hand Therapist Dublin

Ann Garewal (AG), Chelsea and Westminster Hospital, London

Local personnel:

Dr Krishna Lama (KL): Doctor, Director and Surgeon, Lalgadh Hospital, Janatpur

Dr Ananda Sunuwar (AS): Doctor, assistant to Dr Lama

Dr Suraj Maharjan (SM) Plastic Surgeon, Green Pastures Hospital

Dr Dipendra Tamang (DT): Dr, Assistant to Dr Maharjan

Dr Kiran Nakarni (KN): Hand Surgeon, Director of Hand Unit

Dr Lok Chaurasia (LC): Hand Surgeon, Kirtipur

Dr Prawash Bhandhari (PB): Hand Fellow Kirtipur

Dr Puskar Pudasaini (PP): Hand Fellow, Kirtipur

Dr Pradeep Sapkota (PS): Hand Surgeon Anandaban, Kathmandu (visiting during Lalgadh period).

Dr Devendra Maharjan (DM) : Anaesthetist Kirtipur. Engaged and funded to provide anaesthesia in the second week, at Green Pastures Hospital 

Mohan Dangol (MD) Hand Therapist,Kirtipur

Shyam  Paryar  (SP) and Diksha Karki (DK): Hand Therapists, Lalgadh

Birendra Mahara (BM): Orthotist, Lalgadh

Dorothy Das Paryar (DDP): Occupational Hand Therapy trainee, Green Pastures

***

The team flew out of Heathrow on 7th January. FS flew out from Milan on 12th January and joined us at Lalgadh. After an overnight stay in Kathmandu the team flew on to Janatpur and then on to Lalgadh Hospital on the 9th January. Leprosy patients were seen in a screening clinic the same day. Other conditions, particularly burn contractures, were seen in a a second clinic, the following day.

1st Period: Lalgadh Leprosy Hospital

First afternoon and second morning screening and planning of surgery for the rest of the week. Some 50 patients had been assembled and 36 were found suitable for surgery on this trip. 

Over the subsequent 9 days, daily operative sessions were conducted mostly performed by DS as first operator or assisting the other members of the UK (FS and DC) and local team.

PB, Hand Fellow from Kirtipur, Kathmandu and PS, Hand Surgeon from Anandaban, Kathmandu, attended, assisted and performed parts of this operative programme.

The local surgeon, KL was also tutored through various procedures, as were the surgeons on the UK team (FS and DC)

Over previous visits JR has been teaching/mentoring Maneesha, a competent anaesthetic nurse, who subsequently spent a year of training in anaesthesia in Kathmandu. She has become very competent and, under JR’s supervision, performed many of the anaesthetic blocks herself, on this visit,  and including a solo day, after JR’s departure.

KD organised the theatre, helped tutor the local nurses and scrubbed for most cases.

JC and AG ran the therapy, each day getting record of the cases (or observed in person in theatre) and then took over the splinting and rehabilitation. SP, senior Hand Therapist, helped run. The splintmaking/rehab and is also training a new therapist, Diksha, who is very promising, bright, keen.

On the final day, each patient was given a laminated copy of the operation note and a final ward round was conducted, with detailed instructions of the immediate Rehabilitation regime.

JR left Lalgadh on 16th January for a private add-on visit before returning to the UK.

16th January was the day of the tragic plane crash on the flight Kathmandu to Pokhara, a flight the rest of the team was due to take 48 hours later. We chose instead to travel by car, not least because Yeti Airlines suspended its flights for 24 hours and it was also costly to change airline. Two Land Cruisers were rented, with drivers, for the 11 hour+ drive from South East Nepal to Pokhara, west of Kathmandu. (FS, DS, DC, KD, AG, JC).  This used up an entire day of work.

PP (Hand Fellow) travelled to Pokhara to continue his training and we were joined by DM (anaesthetist). Both flew from Kathmandu.

***

2nd period: Green Pastures Hospital, Pokhara.

Some 22 patients had been assembled by SM. 16 patients were suitable for surgery. All patients were assessed on the first day and the week planned. A second clinic was conducted on the second day, with new attendees. Aside from clinic time, all days consisted of operations in theatre.

KD organised the theatres, instruments and setup  along with the staff theatre nurses: Dipu (Sister in charge), Sushila and Samata. Stock was taken of instruments and items were  replenished/exchanged.

JC, AG supervised post operative rehabilitation along with Dorothy Das Paryar (DDP) who performed the  majority of the splint making and rehabilitation. 

JC, (to Ireland) AG, KD (to the UK) left on 28th November. DS, FS and DC finished the week’s work in Green Pastures and went on to Kirtipur.

On the final day, a final ward round distributed laminated operation records and left final instructions for rehabilitation.

***

3rd period: Kirtipur Hospital, Kathmandu

The plan had been to conduct a three day Instructional Course to Kathmandu Hand and general Orthopaedic surgeons. In the event, this formal Instructional Course did not materialise, largely due to poor organisation and preparation by local personnel. Instead, some external surgeons attended and were taught along with the in-house team; this visit contained:

  • A screening clinic when patients were seen, selected and prepared for surgery
  • Two sessions of lecturing (by DS and FS) 
  • Two full days in theatre operating and teaching (DS, FS and DC) groups of observing surgeons and with Kirtipur surgeons assisting. All operative cases formed the basis of teaching tutorials and local surgeons were taught directly as fist assistants.

We returned home on 30th January.

****

OVERALL ASSESSMENT of the various Units

As ever, we have concentrated on the teaching and nurturing of local surgeons, therapists, nurses. It is this which imparts longevity to this project and which, rightly, forms our main focus.

A secondary, no less important, aim is to nurture the visiting team, in this visit FS and DC.  This work requires a particular approach, style, ‘language’ if it is to be maximally effective. Ensuring that the junior surgeons in the team are imbued with this style and also expert at the particular surgery required, also ensures longevity of the project.

So, once again, volume of operated patients took second place to teaching and instructing. A procedure performed by a junior, local, surgeon, assisted by DS, takes a lot longer and, inevitably, the number of operated cases reduces. Nevertheless, long term, the value  increases exponentially as that taught person continues with what he/she has been taught and in turn teaches others.

After the three year gap, the available kit and instruments needed replenishment and this was largely achieved. Some 100 kg of equipment was carried there (thanks also to Qatar airways for a generous baggage concession on the flights out). 

Five pairs of operating loupes (magnifying glasses) were purchased and provided to the new surgeons in Lalgadh, Green Pastures and the two Hand Fellows in Kirtipur.  The need for kit is ongoing – as in previous visits, the final day included a review of what was available and in working order and a ‘shopping list’ assembled for the next visit.

Replenishment of kit is a perennial need but, at time of writing, each of the three units is well set up,  with several sets of instruments for Hand Surgery; extras such as bone instruments; back up kit, such as sterilisers, drills and saws, cauthery machines etc. previously supplied by our team; once again, all consumables were purchased and delivered by the visiting team so that no local stocks were used up. In all three locations, surplus consumables were donated.

Lalgadh Hospital 

The resident doctor/surgeon, KL, also Assistant Director, has retained and improved his repertoire of surgery. A number of cases operated on by him during our absence were reviewed and all were excellent outcomes.

The plan to include Dr Jha Sudhanshu, previously based at Sindhuli has not materialised. Dr Sudhansu has now moved to Kirtipur Hospital. This is a common occurrence – individuals trained to work in one place obtain a move/promotion on the strength of one’s training and move on, defeating the purpose of improving services in the original place. This has happened over the years to a number of surgeons, nurses and physiotherapists we have trained.

Instead, KL has a new assistant Dr Ananda Sunuwar, who is keen to learn more hand surgery. His training has been started.

KL’s daughter Sofi, whose medical studies in China were part sponsored by Working Hands, has returned, as planned, to Lalgadh and is now part of the medical team there. She is intending to specialise in Dermatology – an acute need in the region.

Green Pastures Hospital continues to develop. 

SM is now well established and regularly operates using his training on our visits.  He has a new assistant, Dr Dipendra Tamang, who is a general surgeon and is being trained in Plastic and Hand surgery by SM to be supplemented by training on our visits.

The Hand Unit  in GP owes much to Wim Brandsma (WB), Senior Hand Therapist with many decades of experience. He was meant to travel ahead of us again on this visit, and to assist in patient selection and therapy training but he had to cancel for health reasons. It is hoped that he will attend later this year and Working hands has already funded his visit.

DDP, Occupational Therapist, continues to run the hand rehabilitation and has developed, building on her training with WB, JC and AG. Plans for a period of training for DDP in the UK, in 2020, under the tutelage of AG, were disrupted by Covid and we hope to have enough funds this year, to reconsider.

Kirtipur Hospital Hand Unit now consists of Kiran Nakarni (head), Bishal Karki and Lok Chaurasia as well as two Hand Fellows. 

BK is in charge of all Microsurgery, following his 12 month microsurgery Fellowship in Taiwan,  mainly funded by BFIRST, but part funded by Working hands.  Some of his results were reviewed on this latest visit and they are truly exceptional.  He is a very competent microsurgeon – a real asset to the unit.

The two Hand Fellows: PP completed his Hand Fellowship during Covid and has remained attached to the unit. PB is halfway through his Hand Fellowship. It is of some concern that their training is not comprehensive, indeed, lacking even in some basics – many aspects of Hand Surgery cannot be taught for lack of casemix and suitable expertise.

We learned that KN has established the Nepal Association of Surgery of the Hand (NASH)  intended to bring together all, Plastic or Orthopaedic, with an interest in Hand Surgery.  The first meeting and inaugural dinner, was held on 25th January and we (DS, FS and DC) were made Honorary members. 

During our stay in Kirtipur we were joined by Dr Roberto Maggi, Hand Surgeon from Bergamo who intends to make regular working and teaching visits to Kirtipur and Green Pastures. He is a colleague of DS who also holds a teaching post in Bergamo – hence the connection. He is sponsored by an Italian Charity and is independent of our activity. If he engages in regular visits separate from ours there may be scope for reciprocal review of cases and completion of multistage surgery between the two teams. 

Our presence provided him with a valuable introduction of how we conduct our work and serving as a possible template for his own contribution, reducing his learning curve. How, when and in what form he contributes  in the future is yet to be established.

The Hand Therapy back up in Kirtipur remains excellent, led by  Mohan Dangol, a solo service. (Nhashala Manandhar has left the Hand Therapy unit).

INNOVATION: 

The Lalgadh and Green Pastures visits need no alteration for the present other than our continued periodic presence, guidance and replenishments. Both have new junior surgeons who are keen to learn and to flourish. Much is achieved each day we are there.

The Kirtipur period needs a re-think. While our contribution to the teaching remains valuable, particularly for the Hand Fellowship programme, the time would be better spent in Lalgadh or Green Pastures and with the current Hand Fellow visiting and being taught one on one.     The casemix in Kirtipur does not include Leprosy, which is the main and primary aim of our work.  The plan to teach in Kirtipur in exchange for a visiting surgeon from Kirtipur to travel to Lalgadh in our absence, has not materialised and will not materialise.  This quid pro quo proposal/arrangement has failed (argument over who was to pay) and is another negative against Kirtipur.

This is not to say that our time in Kirtipur is without benefit – only to consider whether it would be better and more constructively spent elsewhere and in another format.

During our time in Green Pastures we learned of other leprosy services run by INF (which also runs Green Pastures). These are in the west of Nepal, particularly, and we learn that there are no Hand Specialists there, while there is great need and a high volume of leprosy paralysis. DS plans to include an exploratory visit to this outpost on the next visit with a view to including this in the cycle, possibly instead of Kirtipur.

2023

1.The next visit is planned for November 2023. The festival season will be over by 19th November and that weekend would be a good time to travel to fit in a visit before Christmas. It will be beneficial to re-establish regular November visits.

Once again the team is likely to consist of 8 personnel and, we hope, also Wim Brandsma, once again sponsored to join us from Utrecht. 

3. Dorothy Das Paryar, Occupational Therapy trainee in Green Pastures may be sponsored, funds permitting, to come to the UK for an intensive training period  with AG in London and DS in Bath and London. This is being explored and costed.

4. We will consider addition of a brief visit to Shining Hospital Banke, leprosy hospital in the west of Nepal, to explore possible future work there.

   FUNDING

During the Covid years funds have run low for two reasons:

  1. Contributions largely dried up. The impetus of annual visits, the build up to each trip and publicity, were all lost.
  2. In lieu of visits, lump sum funds were sent directly to support various services in Lalgadh and Kirtipur in particular and in response to direct pleas on their part.

The link with Etihad has been lost. Etihad no longer flies to Kathmandu and their valuable sponsorship, in the form of ex gratia flights, was lost. This is a severe financial blow since the flights represent the largest single expense of this work.

The money donated by the Hilden Charitable fund was kept and spent on the January 2023 visit.

James Rogers generously funded his own return flight London to Kathmandu.

James Lowther, our accountant, who provided immensely valuable advice in setting up the Charity and has done the accounts, unpaid, since the start, has retired.  Seamus MacDonald, accountant based in Bristol, has kindly agreed to take over the accounts.

  • In the run up to this latest visit valuable  contributions came from Sulis Hospital  Bath (most consumables), Solent Stevedores (£5k contribution to flights).
  • There were many individual contributions, some on standing order of small amounts each month. These add up over the year.
  • Some funds were generated by DS illustrations which were sold or rented (for brochures and programmes) and by DS lecturing. Mercian, Instrument makers, continue to support by giving a substantial discount in purchased instruments and also by commissioning DS to provide illustrations for their new brochure, the fee for which went into the Charity account.
  • DC was sponsored by the BSSH (British Hand Society) with a bursary which meant her inclusion was largely cost-neutral. Application will be made in time for the next visit for similar bursaries for other members of the team who are also members of the BSSH. 
  • JC raised a considerable contribution by virtue of a sponsored swim off the Irish coast.
  • DS runs an Anatomy Dissection course in Bristol and this is handled via the Working Hands account. It has generated valuable funds without which the January 2023 visit would not have been possible, in these lean times. In effect, the leprosy project has borrowed from the Anatomy course surplus funds. This encroachment into the Anatomy resources will have, largely, to be repaid.
  • All contributors have been listed amongst the Benefactors on the Working Hands website
  • Qatar Airlines have been approached with a view to requesting sponsorship in the form of ex gratia return flights. Various other sources of funding will be explored.

Donald Sammut

Bristol 6th February 2023

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