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Report November 2023

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REPORT ON ACTIVITIES OF WORKING HANDS: NOVEMBER 2023

Note: This year, 2023, was exceptional in containing two visits, one in January and a second in November

Working/Teaching trip organised November 2023, to:

Lalgadh Leprosy Hospital, Janatpur

Green Pastures Hospital, Pokhara

Kirtipur Hospital, Kathmandu

Activity:

  • Teaching and tutoring of local surgeons and visiting team
  • 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: 6 personnel
  • Delivery of some 120kg of kit, instruments, crutches and aids, consumables

25th November to 13th December 2023

Periods spent in the three hospitals:

1st period: Lalgadh Leprosy Hospital, Janatpur: 27th November to 4th December

2nd period: Green Pastures Hospital, Pokhara: 4th to 11th December

  • Team: 

Surgeons: Christina Lipede (CL) Hand Surgeon, Birmingham

Andreea Lupu (AL) Hand Surgeon, Hexham, Newcastle

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

Francesca Susini (FS), Hand Surgeon, Milan

Theatre Nurse: Trudy Davies (TD) Operating Department, Bath

Hand Therapist: Jean Cahill (JC), Hand Therapist Dublin

Wim Brandsma (WB): Hand Therapist, Utrecht, Holland

Local personnel:

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

Dr Shyam Thakur (ST) Orthopaedic surgeon, Lalgadh Hospital

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

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

Dr Bishal Karki (BK): Hand Surgeon Kirtipur, Kathmandu

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

Mohan Dangol (MD) Hand Therapist,Kirtipur

Maneesha Nepali (Anaesthetic nurse/operative

Dr Sanjay Yadav (SY) anaesthetist  

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 assembled in Heathrow from various directions (Newcastle, Birmingham, Milan, Dublin, Bristol) on 25th November. After an overnight stay in Kathmandu, and a meeting with the Kirtipur surgeons, the team flew on to Janatpur and then on to Lalgadh Hospital on the 27th November. 

As usual, the same afternoon, a screening clinic was conducted, where some 40 patients were reviewed and scheduled for surgery later in the week.

A second clinic was conducted the following day and individual patients were seen on various days throughout the stay, usually at the Theatre door.

1st Period: Lalgadh Leprosy Hospital

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

Locals:

KL Surgeon and Medical Director, Lalgadh, 

PS, Surgeon from Anandaban, Kathmandu, Kathmandu and BK Hand and Microsurgeon from Kirtipur, Kathmandu. (BK and PS travelled from Kathmandu to attend this surgical camp. BK also accompanied us to Pokhara and was present, observing, assisting and learning on each clinical day of the entire visit)

Maneesha, in Lalgadh, has developed into a very competent anaesthetic nurse (tutored on previous visits by James Rogers, our anaesthetist, and currently doing more formal anaesthetic training which she interrupted to joi us) capable of providing reliable regional blocks. On this Lalgadh visit, she performed virtually all the regional anaesthesia, sedation etc. 

TD organised the theatre, conducted stocktaking and organisation of stores, helped tutor the local nurses and scrubbed for most cases.

JC ran the therapy, continuing with her tuition and mentoring of Diksha. SP, senior Hand Therapist, has now retired but was brought back on limited contract to coincide with our visit. 

On the final day, as is usual practice, a final ward round was conducted, each patient seen, and instructions on their ongoing care finalised. Each patient was then also given a laminated copy of his/her operation notes (mostly in images/annotated drawings – see galleries), for their record and also to provide to any other surgeon who might, in the future, operate on the same hand. 

***

2nd period: Green Pastures Hospital, Pokhara.

Patients had been assembled by SM and by WB who had been, once again, part supported by Working Hands, to attend GPH and select patients and participate in the work and teaching. All patients were assessed on the first day and the week planned. As is usual, other patients trickled in throughout the week and were assessed and added to operating lists new. Aside from clinic time, all days consisted of operations in theatre.

Once again there has been a change in nursing personnel – Dipu, senior nurse, has moved to the UK.  This brain and talent drain is, alas, a recurring problem. TD organised the theatres, instruments and setup  along with the staff theatre nurses. Stock was taken of instruments and items were  replenished/exchanged.

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

On the final day, a final ward round distributed laminated operation records and left final instructions for rehabilitation.  There was a disappointing volume of patients for surgery in this visit but the ones that were operated provided valuable teaching opportunity, which is the more important aspect of these visits.

In both Lalgadh and Green Pastures, DS organised and delivered didactic teaching, particularly in Anatomy and Biomechanics of the hand. This supplemented the constant, hands-on, clinical teaching in the operating theatre and in clinic.

***

Returns home:

The entire team left Lalgadh on 4th December. JC and TD flew on from Kathmandu (JC to Dublin, TD to London) while the rest of the team flew on to Pokhara.

The team then returned to Kathmandu on 11th December and FS flew straight on to Milan.

The remaining members of the team (AL, CL, and DS) flew home, to London, early on 13th December.

****

ASSESSMENT of the various Units

The main scope of these trips remains the instruction, teaching and mentoring of local surgeons and other personnel. It is they who work all year round, in the places we visit.  It was gratifying to review a number of cases managed by locals and to see that these had been done to a high level.  SM, in Pokhara, has developed into a fine hand surgeon, particularly un the repertoire required for leprosy reanimation.

A secondary, no less important, aim is to nurture the visiting team, on this visit FS, CL and AL . FS has been on our team in January of this year, but the work, environment and approach were entirely new to AL and CL.

The local surgeons who have been mentored repeatedly over the years are BK, KL, SM, and PS. They have become truly expert at the repertoire of diagnoses and interventions that have been repeatedly performed in these visits and perform this to a high standard.

On this trip, some 120kg of kit was taken out (thanks also to a 45 kg baggage concession by Qatar air). This included a full core driver set, wires drivers, drill and sagittal saw, which were taken to Lalgadh hospital. For a number of years we have been coping in Lalgadh with very simple (in fact, literally, veterinary) equipment. This has now been upgraded to equipment of a level we use in the UK. The core driver was kindly donated by Sulis Hospital, Base hospital of DS, when the in-house core drivers in Bath were replaced.

Single instruments such as tenotomy scissors , fine forceps etc were donated from DS’s personal sets and will be replaced on return to the UK.

All consumables were carried by us and used on this trip. No local stores were depleted. These consumables were, once again, kindly donated by Sulis Hospital, Bath.

Lalgadh Hospital 

The resident doctor/surgeon, KL, also Assistant Director, continues to perform all surgery in our absence (admittedly a low volume through the year).

A new Orthopaedic assistant has been taken on: Shiyam Thakur (ST). This young surgeon is Orthopaedic in training and his instruction and training in leprosy surgery was commenced on this visit.

The physiotherapy is ably handled by DK. We hope to be able to fund a month of training for in the UK, under the tutelage of Ann Garewal in London

KL’s daughter Sofi, remains  part of the medical team there. She intends to specialise in Dermatology – an acute need in the region – and on this visit a high spec Dermoscope was delivered to her.

Green Pastures Hospital remains a project under development under the guidance of WB and the work performed by SM. 

SM has developed into a fine hand surgeon, with a repertoire of reanimation of the paralysed hand. On this visit, DS assisted him on a number of interventions and, in truth, he needed little guidance.  His assistant, DT, is receiving training by SM  supplemented by training on our visits.

There is a perceived problem with sourcing patients at GPH. There is a significant demand for leprosy surgery in the Far West region, but most patients cannot afford to travel to GPH. This is being addressed – we have plan to go to the patients instead; on the next visit we will omit or curtail the stay in Pokhara and go direct to Surkhet, in the Far West, setting up a leprosy hand service there.

Wim Brandsma (WB), Senior Hand Therapist with many decades of experience is now virtually retired in Utrecht, Holland. Once again his experienced input was much valued.  He was there ahead of us and stayed on after we left, instructing DDP

DDP, Occupational Therapist, continues to run the hand rehabilitation in collaboration with BM. 

INNOVATION: 

On this visit we concluded that there is little scope in continuing with our visits to 

Kirtipur Hospital, not least because little leprosy surgery is seen there.

Instead, there was much discussion on the exploration of work in Surkhet Hospital. Green Pastures serves the entire west of Nepal, including the remote Far West, and on this visit very few patients made the laborious (12 hours by bus) journey to come for surgery at GPK. On the next trip, in November 2024, instead of a week in Pokhara, we plan to organise instead a week or more  in Surkhet, and in the company of SM and DD. This means that we will go to the patients instead of having them travel arduously and expensively, to Pokhara, where, in addition they would have to be housed and fed. 

There are direct flights to Surkhet from Kathmandu and we can bypass Pokhara.

Much depends on the Hand Therapy backup since we would not wish to operate if the rehabilitation services were not of adequate standard, hence the inclusion of DD on our team. Planning for this additional stay will continue during 2024.

2024

1.The next visit is planned for November 2024. The festival season will be over by 7th November and that weekend would be a good time to travel to fit in a visit before Christmas. 

Once again the team is likely to consist of 8 personnel. The actual make-up of members remains to be established. It is hoped that Wim Brandsma will be up to travel to join us, once again sponsored by Working Hands.

3. Diksha  Karki, Occupational Therapy trainee in Lalgadh 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.   It had been planned to invite Dorothy Das but she has actually recently spent a month in Europe, in Germany and Utrecht (with WB) and instead, it is DK who will be invited.

4. Moving our activity from Green Pastures, Pokhara, to Surkhet, will represent a major change, and an addition to our activity.

5. There is no intention to continue with any significant attendance at Kirtipur Hospital, which has adequate Hand Personnel, although occasional teaching there is not excluded and the members of the Kirtipur Hand team remain welcome to join us (as did BK, on this latest visit).

   FUNDING

This remains a perennial problem year on year, although, to date, no visit has been cancelled or curtailed for lack of funds. Each year, kind and generous benefactors come through and fund the next visit, often unsolicited.

Each visit costs on average, some £10,000, the largest single expense being the flights. No donated funds are wasted and all donations and raised revenue go directly to funding aspects of the trip, including the purchase of kit to transport.

None of the team’s members are paid and all give their time and expertise free. 

  • Qatar Air, contributes in the form of generous baggage allowance. 
  • There is no regular and established form of funding although, these past two years, Solent Stevedores, on personal contact, have defrayed the majority of the expense on flights (£5k of the average £7k).
  • Various other sources of funding,  will be explored, particularly from institutions and individuals willing to commit to a period of  sponsorship so that one can depend on funding for a few years at a time.

Donald Sammut

Bristol 5th January 2024

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