Report on the Charity’s activity in 2017

Summary:

• Working trip organized to Lalgadh Leprosy Hospital November/December 2017
• Delivery of some 90kg of kit and consumables
• Teaching trip organized to Kathmandu Kirtipur Hospital, December 2016 and developing ongoing teaching and training commitments
• One funded Fellow in Bristol October/November
• 2017 Fundraising.

–       Plans and development/ongoing programme

The working trip was organised for the period 15th November to 3rdDecember 2017. The Members of the team:

Nola Mackie(NM): Senior Plastic Surgery Trainee, Oxford rotation

Donald Sammut (DS): Consultant Hand Surgeon, Bath

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

Marc Bransby Zachary (MBZ): (Retired) Consultant Hand Surgeon, Glasgow

Rebecca Shirley (RS): Consultant Hand and Plastic Surgeon, Stoke Mandeville Hospital, Aylesbury

In addition, the Local (Nepali) members were:

Dr Devindra Maharjan (DM): Anaesthetist. This doctor travelled with us to Lalgadh as a last minute arrangement to replace James Rogers who had to cancel because of a close family bereavement.

Dr Bishal Karki (BK): Plastic Surgeon in Kathmandu. He Travelled to Lalgadh as part of the team and to be taught leprosy surgery. (See below ‘Teaching/future plans)

Dr Suraj Maharjan (SM). A new addition, a young surgeon who is to take up the post of leprosy surgeon in Green Pastures Hospital Pokhra but has no leprosy experience. He joined our Lalgadh team to learn and there is plan of more focussed intensive teaching of this surgeon (See ‘Teaching/ Future Plans’)

Lalgadh Hospital 16th to 24th November (Full team except WM):

The team travelled from Kathmandu by internal flight to Janakpur. Following the usual pattern, the working week started with a review of all patients who presented for care. These included a very familiar assortment, mostly leprosy paralysed hands, but also numerous burn contractures and some congenital hand malformations along with an assortment of cysts and tumours. These were scheduled for surgery and the operative programme planned, with surgery starting the following day.

The relatively low volume of cases this time coincided with the larger number of those who needed teaching and this permitted intensive, one-on-one teaching of all members of the team. DS performed the first of each new type of surgery and subsequently each member of the team, in turn, operated as first operator with DS assisting.

Most days started with a tutorial (DS) on relevant topics such as Median and Ulnar paralysis or pure anatomy and biomechanics.

We were able to operate on all those who presented for surgery, and who were suitable. One child, a difficult intubation with a severe burn contracture of the axiola, was transferred to Kathmandu and DS was able to operate on this child in Part 2 of the visit.

As ever, the overriding aim of the visit was the training and teaching of local surgeons.

–  One Hand Surgery trainee from Kirtipur, Kathmandu, BK who has previously come to the UK as BSSH Fellow, observed all operations and was assisted in performing others. He has recently qualified as Plastic Surgeon in Kathmandu (the equivalent of CCST) and remains our best trainee in Nepal, well capable to taking over or supplementing our leprosy work there.

–  A new Nepali surgeon SM joined our team. He has recently qualified and is intending to establish himself in Pokhra, as Leprosy and Plastic surgeon there. His training with DS has just started (See ‘Teaching/FuturePlans’)

–  NM, RS and MBZ all performed surgical procedures, including a number of complex tendon transfers, assisted by DS.

Anaesthesia was provided by a very capable anaesthetist from Kathmandu (DM) who was funded to travel with us and paid for his work. James Rogers and Sam Gidwani were unable to come on this trip for compelling family reasons – they remain core members of the team. Virtually all limb surgery was performed under regional anaesthesia and the rest under ketamine/sedation. DM required Ultrasound to perform his blocks and fortunately Lalgadh possesses an Ultrasound machine (never previously used for anaesthesia) which was used very effectively.

Some 90 kg of equipment was delivered to Lalgadh/Kirtipur on this visit, including diagnostic kit, Physiotherapy equipment, new instruments and all consumables used in our work there. It is one of the gratifying features of the Lalgadh work that all kit we deliver on each visit is cared for and used effectively. The Etihad blankets were still in use on all patients, the steriliser in action, all fine instruments undamaged. Over the years, Lalgadh has been kitted out very effectively, both in the operating theatre and on the wards and the standards of care consequently raised.

On the 2016 visit we introduced the practice of lamination of the DS operative drawings for each patient. These were given to each individual at discharge and it was also gratifying to see that a number of patients returned with these laminated records, seeking further care or surgery to the other hand. This single additional practice has made a significant difference in patient management since, by and large, record-keeping both in Lalgadh and Kathmandu, is poor.

At the end of the visit to Lalgadh, all flew back to Kathmandu, with NM and RS flying on to the UK while DS and MBZ transferred to Kirtipur hospital, Kathmandu to continue work and teaching.

 MBZ stayed until 28th Nov and DS until 2nd Dec. An instructional Hand Surgery Course was meant to be organised, as in previous visits, to coincide with this stay for surgeons in other units in Kathmandu. This did not materialise largely as a result of inefficiency/inertia on the part of the Kirtipur team and a series of informal lectures were delivered instead to the in house department by DS, MBZ and WB.

A number of operative cases were chosen for their teaching potential, performed with the local Hand Trainees in the team.

Shankar Rai was ill throughout this period and unable to attend for most of this part of the trip and we were unable to discuss future projects on this occasion. The Hand Fellowship is still to go ahead and DS will be one of the tutors, when this is set up. It is hoped that a Hand Fellowship in the UK will form part of such a set-up, in the future.

The link with Kirtipur has also been exploited in the set-up of surgical camps in Lalgadh at other times of the year. It is hoped/expected that these will deal with relatively routine surgery such as burn contractures, leaving the more complex leprosy work to the November Working Hands visits, The first such camps was conducted by the Kathmandu team, in Lalgadh, in October 2017.

Fundraising and revenue

This year the Charity suffered a major setback to its finances – Etihad Airline had kindly and very generously  sponsored the flights, our single biggest expense, for the previous seven years and, this year, regrettably withdrew their support. This required the allocation of some £4300 to the purchase of flights. One new sponsor, Solent Stevedores, stepped in through personal contact with DS, and kindly provided this unplanned expense

The withdrawal of Etihad flight support also had implications on the baggage allowance. Flights were purchased through Qatar air who conceded a modest extra allowance but we were obliged to limit the carried kit to a minimum. This serious setback will be discussed over the coming year. It will require the generation of more revenue.

 Once again there were numerous donations and solicited funds, some regular standing orders from patients and supporters, and some more substantial one-off donations. David Evans, retired surgeon and pianist, organised a recital (Schubert’s Die Wintereisse) with tenor Charles Luxford) nominating Working Hands as charity and £1,000 was raised by ticket sales for the evening.

Teaching/Future Plans

1. Nhashala Manandhar, Hand Therapist, was sponsored jointly by BSSH and Working Hands to spend a six week period in Bristol, learning Hand therapy techniques and general hand surgery. She divided her time between attendance at Southmead Hospital, Bristol, where she shadowed Hand Therapists as well as the Burns Adult Scar Therapists and DS practice in Bath. She was also tutored by DS’s Hand Therapist in Bath, Claire

Her report and a report on her visit by Working Hands, has been provided.

2. The essence and most important feature of this work is the teaching element and sustainability. On this visit two UK surgeons (RS and MBZ) were included in the team as ‘buddies’ in order to learn first-hand one approach to setting up, conduct and ongoing maintenance of such a project. This started through the months of run up to the actual trip with frequent communication regarding the organisation and inevitable problems that arose. During the trip, both received intensive exposure to all aspects of this type of work, from the diagnosis in clinic, the actual surgery, to the prioritisation of care, the limitations and consequent adjustment of working practice, the dialogue with local teams, and the nurturing of good practice in the personnel who would implement what has been taught on the trips. Both received a good immersion in this work and it is hoped that they will be encouraged to set up their own projects elsewhere and to put into practice what has been learned.

3. In addition, two very promising local surgeons, one known (BK) and one new (SM) were included in the team, observing clinics and surgery. Both were assisted by DS in the performance, as first operators, of relatively complex tendon transfer procedures. The aim is to improve their calibre of surgical care such that they will able to deliver this in the rest of the year and long

4. SM is a new protégé in this work and DS plans to contribute strongly to his further training. He has recently qualified in China, as Plastic Surgeon, and is to take up a post as Surgeon in Green Pastures Hospital which used to be a major leprosy centre but which no longer offers the service. There is a move to revive this, funds permitting, under the care of WB, and to install SM as main surgeon. DS has agreed, in principle, to travel there for an intensive week of training, possibly in March 2018, to tutor him and to provide some kit (also funds permitting). This will be a stand-alone visit independent of the planned full team visit in November 2018*.

Future activities

Further trips to Nepal are planned for March ( DS alone to Green Pastures, Pokhra) and November 2018 (The extended team to Lalgadh, Green Pastures and Kirtipur).

Donald Sammut
Bristol, January 2018

Addendum

*Since submitting this report the planned trip of November 2018 have been pushed back to January 2019, since many of the major Nepali festivals fall in November in 2018 .