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Note: The November 2018 visit was deferred to January 2019 to avoid festival dates and this visit is included in the 2018 activities
– Working trip organised to Green Pastures Hospital March 2018
– Delivery of kit, instruments, consumables
– Teaching, mainly of new surgeon Suraj Maharjan and Bishal Karki, Hand Surgery Fellow, visitor from Kirtipur
– Team: Donald Sammut (DS)
– Working trip organised January 2019, to:
Lalgadh Leprosy Hospital, Janatpur
Green Pastures Hospital,Pokhara
Kirtipur Hospital, Kathmandu
– Delivery of some 200kg of kit, instruments, consumables
– Teaching and tutoring of numerous surgeons in all three venues
– Teaching and organisation of nursing services in theatre Lalgadh and Green Pastures
– Teaching and organisation of Hand Therapy services in Lalgadh and Green Pastures
– Conduct of formal Instructional course to 40 surgeons and other personnel (DS) in Kirtipur Hospital, Kathmandu
– Team: 9 personnel

22nd to 30th March 2018
Surgical Trip to Green Pastures Hospital, Pokhara

Green Pastures is a Leprosy and general hospital run by Nepal Leprosy Trust, based in Birmingham. It was once a major hub for leprosy surgery but effectively ceased major work some 10 years ago. It is in the process of revival, with a busy ENT unit, Spinal surgery unit and, established more recently, a fledgling Plastic and Hand surgery service.
This latter is now led by Suraj Maharjan (SM), who qualified in Plastic Surgery in 2017 and has been engaged to build up this service.
DS has taken on SM’s training and travelled there for one week as a solo mission, to operate, teach, and assess the requirements.
During this visit, Hand Surgery operations were performed by DS in Green Pastures after a gap of some 10 years.

Wim Brandsma (WB) a senior and experienced Hand Therapist from Holland is also heavily involved in the establishment of a Hand Surgery service in Green Pastures and this process is now well advanced. WB visits Green Pastures 2 or 3 times a year.
During this visit the instrument needs for the Unit were assessed (and much already delivered), formal lectures/tutorials were delivered daily and clinics and surgical programmes were conducted, all involving training and tutoring of SM.

12th January to 3rd February 2019
Surgical trip to Lalgadh, Green Pastures and Kirtipur

This visit was carried over from November 2018 (numerous national and regional festivals fell in November – experience dictates that most will not consent to surgery during these periods and the visit was put back to January).

– Team:
Surgeons: Donald SAMMUT (DS), Hand Surgeon, Bath and London
Sam Gidwani (SG), Consultant Hand Surgeon London
Fadi Issa (FI), Senior Plastic Surgery Trainee, Oxford
Anaesthetist: James Rogers (JR), Consultant Anaesthetist, Bristol
Theatre Sister: Trudy Vaughan-Brooks (TVB), Theatre Manager/sister, Bath
Hand Therapists: Jean Cahill (JC), Ann Garewal (AG), Hand Therapists from Chelsea and Westminster Hospital, London
Wim Brandsma (WB): Senior Hand Therapist, Utrecht, Holland
Medical Student: Elena Hughes (EH), Neuroscience student, John Hopkins University, USA (soon medical student)
Local personnel: Dr Devendra Maharjan (DM) : Anaesthetist. Engaged and funded to provide anaesthesia in the second week, at Green Pastures Hospital
Dr Lok Chaurasia (LC): Hand Fellow from Kirtipur, who joined the team for the full three weeks for training.
Dr Krishna Lama (KL): Main Doctor and Surgeon, Lalgadh Hospital, Janatpur

This 3 week visit was divided between three hospitals:
1st week: Lalgadh Leprosy Hospital, Janatpur
2nd week: Green Pastures Hospital, Pokhara
3rd week: Kirtipur Hospital, Kathmandu

1st Week: The full team flew out of Heathrow on 15th January with some 200kg of kit, instruments, consumables. We were joined by Dr Lok Chaurasia (LK) Hand Fellow from Kirtipur, for training. Numerous patients (approx. 60) had been assembled in Lalgadh and a clinic was held to assess each one on the day of arrival. After that, each day consisted of an average of 7 major operations per day. Members of the team took turns to assist or perform various interventions under tuition by DS.
TVB re-organised theatre procedures and stores and, with each case, tutored the local theatre nurses.
JC and AG worked closely with the Lalgadh therapists to splint and start rehabilitation of all patients as they came out of the operating theatre and in subsequent days.
WB went on to Green Pastures to help assemble the patients there and to prepare for the 2nd week.
On the final day, all patients were reviewed and final instructions on rehabilitation delivered. As on each visit, each patient was given a laminated copy of the surgery records, including drawings and detail of the procedure.

JR, FI, SG and EH returned to the UK at the end of this first week.
DS, JC, TVB and AG travelled on to Pokhara. LC also travelled to Pokhara to continue his training.
2nd week: We were met by SM and WB and some 30 patients who had been assembled. Once again, the pattern of work was the same – all were assessed on the first day (and a steady trickle of other patients came to be assessed on each subsequent day) and the week planned out. After that, each day consisted of a lecture/tutorial (by DS) to the hospital personnel followed by a full day in the operating theatre.
A considerable amount of kit was delivered to Green Pastures on this visit, such that the Hand Unit now has all basic instruments to perform a full repertoire of Hand Surgery. They lack mainly a reliable electric drill/saw/driver and provision is planned for the future. Other needs have been noted.
TVB trained the (new) theatre staff and also organised theatre procedure and set-up.
JC and AG worked with WB to kit out, teach and demonstrate splint-making and rehabilitation of the patients who were operated.

TVB, JC and AG returned to the UK halfway through this second week and DS continued with a solo visit, teaching and operating.
On the final day, a final ward round distributed laminated operation records and left final instructions for rehabilitation.
3rd week: DS, WB and SM flew on to Kathmandu.
An Instructional Course had been organised in Kirtipur Hospital, to include some 40 surgeons from around Kathmandu as well as the entire Kirtipur unit and visiting students.
The first day was one of review of assembled patients.
The second day was one of didactic teaching conducted by DS who delivered 9 lectures, back to back. The themes of this course: Anatomy of the Upper limb, The Paralysed Hand, Hand Reconstruction and Tendon Transfers.
The rest of the week consisted of operating on selected cases which were filmed and transmitted live to the hall with the assembled surgeons as well as a live sound link from DS to the hall with a constant commentary, question-and-answer.
The local Hand Surgeons, led by Dr Shilu Shrestha plus the Hand Fellow (LC), received one-to-one training.

Once again considerable kit was delivered to Kirtipur, including a full electric saw/drill/driver set kindly donated by De Souter Ltd in the UK.

DS returned to the UK on 3rd February.

Once again, as will be seen from the above account, the main focus has been on training and mentoring of personnel. The local surgeons received considerable one on one tuition by DS as well as a very comprehensive instructional course in Kirtipur. Each visit continues to increase local repertoire and confidence.
Both LC (Hand Fellow from Kathmandu) and SM (Surgeon Green Pastures) were tutored intensively by DS throughout the visit.

In addition, the UK team continue to be taught not just the surgery but also the various aspects of set-up, conduct and perpetuation of this particular work. The aim of the entire project is that it should train others and by doing so, make the work sustainable. Each person who joins the team is enthused to continue with this work, set up his/her own project or bring expertise to other teams.

The Lalgadh service would appear to be conducting very little elective surgery in the periods between our visits. This is partly because the main doctor/surgeon, Krishna Lama (KL) has just returned from a 12 month training period in Indiana, USA where he received intensive training in Dermatological Surgery. It is unlikely that KL will have significant time to dedicate to surgery in Lalgadh in the near future since he is mainly concerned with outpatient dermatological work, a well as his role as chief clinician of the hospital with considerable and increasing administrative duties. In the immediate future, surgery at Lalgadh will continue to be mainly performed on our visits and on any visiting camps conducted by Prof Shankar Rai’s team from Kathmandu. These visits have, for some reason, not taken off and they will be explored further.

Green Pastures Hospital carries great promise and the intention (and hope) is that it should become the hub for hand and leprosy surgery for the west of Nepal providing a service for patients who currently go untreated or travel to Kathmandu for surgery. The intensive training of Suraj Maharjan is paying off and he is increasingly autonomous and confident in handling complex hand cases. Later this year he will be joined by a Plastic Surgeon from the USA who is relocating to Green Pastures.
Wim Brandsma continues a very fruitful collaboration with DS. WB has taken on the organisation of the Hand Therapy services and a share of mentoring of SM. He was funded by Working Hands to join us on this visit to help assemble, assess and rehabilitate the many patients who were treated. He remains crucial to the Green Pastures project.
It is hoped that JC and AG (Hand Therapists) will form part of the team in November and, if this does come about, there is plan to organise a splint-making and hand rehabilitation course in Green Pastures. This will be led by a faculty consisting of JC, AG, DS and WB. This will instruct therapists from much of Nepal and also help consolidate Green Pastures on the leprosy surgery network.

The Kirtipur Unit is led by Shankar Rai who remains a remarkable leader of his team with vision and expertise. Under his guidance the relatively new Unit at Kirtipur has built a Burns Service, Cleft unit and Hand Unit, as well as a general Plastic Surgery repertoire. DS’s association with the unit remains one of training the team. Dr Shilu Shrestha, an Orthopaedic surgeon who has had Hand Surgery training in Singapore, has recently joined the unit as the senior Hand Surgeon. Bishal Karki, another expert Hand Surgeon is currently half way through a dedicated Microsurgery fellowship in Taiwan. He will return and share the Hand Unit with Dr Shrestha. The Hand Fellowship is in its second year and DS remains committed to continue with particular training of the Hand Fellow, and with the Hand Surgery training of the Unit generally.


The next visit is planned for 16th November 2019 and will, likely, once again consist of 3 weeks by DS and a number of team members who will return to the UK in stages. The size and make-up of the team will rather depend on funding, as ever. Etihad has kindly resumed provision of flights, otherwise our largest single expense. Provided this crucial help is once again forthcoming (there is no guarantee), the plan is to assemble another team of some eight personnel.
Teaching and tutoring remains the main thrust of this entire project. This is extended to the local Nepali surgeons as well as the home team from the UK.

Funds permitting, we would wish to organise a six week Observer period in the UK for the main theatre nurse, Sushma Bishwakarma, from Green Pastures – the plan would be that she would shadow TVB with whom she has established a working/mentoring relationship as well as some work with DS in Bath.

We are exploring the set-up of ongoing tuition with a live internet link so that DS can continue with monitoring and preparation of patients, conducting tutorials and, most importantly, contributing to the ongoing training of the Hand Fellow in Kirtipur.
Note has been taken of the next stages of kit provision and this will depend on available funds.


Main sources of income during 2018:
– The single largest contribution has been the provision of flights by Etihad Airlines. This year has seen their biggest contribution yet – provision of return flights for DS in the March 2018 trip and for all 8 members of the team for the January 2019 trip. This single contribution frees our funds for the expenses related to the travel and the purchase of kit. As a direct result of this contribution, on the January 2019 we were able to purchase, assemble and transport some 200 kg of kit, including some £5000 worth of hand instruments to distribute amongst the three hospitals

– A one-off generous donation of £3000 was received from the Souter Charitable Trust.

– Important, small, regular contributions continue throughout the year from individual benefactors.

– London Bridge Hospital once again donated a grant of £1000 through the contact with Sam Gidwani who is part of the team

– Fadi Issa received funds towards his trip expenses through the BSSH Education Committee.

– Jean Cahill and Ann Garewal, Hand Therapists on our team, raised approx £4000 through sponsorship by friends and relative and a sponsored swim.

– David Evans, retired surgeon and pianist, raised £700 with a London recital of Schumann song cycles, in collaboration with baritone Charles Luxford

– Numerous firms have effectively donated by granting substantial discounts in kit. Mercian Instruments are to be singled out for granting a regular 25% reduction on catalogue price for all instruments.

– Circle Bath Hospital granted the sum of £600 towards the purchase of consumables (needles, syringes, dressings etc for use on the trips).

– Funds also accrue from the sale of DS illustration work, from lecturing in schools and institutions and from one off donations by DS patients

Donald Sammut
Bristol 16th February 2019

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