REPORT ON ACTIVITIES OF WORKING HANDS: 2019
Note: The November 2018 visit was deferred to January 2019 to avoid festival dates; report on that visit was included in the 2018 activities
Working/Teaching trip organised November 2019, 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
- Teaching and organisation of Hand Therapy services in Lalgadh and Green Pastures
- Teaching and organisation of nursing services in theatre Lalgadh and Green Pastures
- Conduct of lecturing and tutorials (DS) in Green Pastures Hospital, Pokhara, and Kirtipur Hospital, Kathmandu
- Team: 9 personnel
- Delivery of some 120 kg of kit, instruments, crutches and aids, consumables
17th November to 6th December 2019
Periods spent in the three hospitals:
1st week: Lalgadh Leprosy Hospital, Janatpur: 18th to 24th November
2nd week: Green Pastures Hospital, Pokhara: 24th November to 2nd December
3rd week: Kirtipur Hospital, Kathmandu: 2nd to 6th December
- Team:
Surgeons:
Sam Gidwani (SG), Consultant Hand Surgeon London
Caroline Leclercq (CL), Consultant Hand Surgeon, Paris
Nola Lloyd (NL), Senior Plastic Surgery Trainee, Oxford
Donald Sammut (DS), Hand Surgeon, Bath and London
Anaesthetist:
James Rogers (JR), Consultant Anaesthetist, Bristol
Theatre Sister:
Trudy Vaughan-Brooks (TVB), Theatre Manager/sister, Bath
Hand Therapists:
Wim Brandsma (WB): Senior Hand Therapist, Utrecht, Holland
Jean Cahill (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 Suraj Maharjan (SM) Plastic Surgeon, Green Pastures Hospital
Dr Bishal Karki (BL): Consultant Hand and Plastic Surgeon Kirtipur
Dr Lok Chaurasia (LC): Registrar Hand Surgery, Kirtipur, with the team for the full three weeks for training.
Dr Jha Sudhanshu: Orthopaedic Surgeon, Lalgadh and Sindhuli Hospitals
Dr Devendra Maharjan (DM) : Anaesthetist. Engaged and funded to provide anaesthesia in the second week, at Green Pastures Hospital
Dr Shilu Shrestha (SS) Consultant Hand Surgeon, Kirtipur
Mohan Dangol and Nhashala Manandhar: Hand Therapists Kirtipur
Shyam Paryar and Krishna Subedi: Hand Therapists in Lalgadh Hospital
Dorothy Das Paryar: Occupational Hand Therapy trainee, Green Pastures
***
1st Week: The team flew out of Heathrow on 16th November and, after an overnight stay in Kathmandu flew on to Janatpur and then on to Lalgadh Hospital on the 18th, starting work (outpatient screening of patients) the same afternoon.
The pattern of all previous visits was followed: First afternoon screening and planning of all surgery for the rest of the week. Some 45 patients had been assembled and some 25 were found suitable for surgery on this trip. The addition of CL (an eminent cerebral palsy specialist) to our team widened the scope of this screening clinic.
The rest of the week consisted of daily operative programmes in theatre. Additional patients appeared throughout the week. Members of the team took turns to assist or perform various interventions under tuition by DS and CL.
JR performed or supervised local personnel in the delivery of anaesthetic blocks. One anaesthetic nurse, Manisha, who had received advanced anaesthetic training in Kathmandu during 2018/9, as well as on our visits, was able to perform the majority of blocks under his supervision.
TVB organised theatre procedures and stores and, with each case, tutored the local theatre nurses. On this trip she was able to set up, and ‘run’, in theatre, while the local personnel worked under her supervision.
JC and AG worked closely with, and taught, the Lalgadh therapists to splint and start rehabilitation of all patients as they came out of the operating theatre and in subsequent days.
WB flew direct to Green Pastures to prepare for the 2nd week.
On the final day, all patients were reviewed and final instructions on rehabilitation delivered. As on every other visit, each patient was given a laminated copy of the surgery records, including drawings and detail of the procedure.
JR, SG returned to the UK, and CL returned to Paris, at the end of this first week.
DS, NL, JC, TVB, AG travelled on to Pokhara.
LC (surgeon) travelled to Pokhara to continue his training and we were joined by BK (surgeon) and DM(anaesthetist).
***
2nd week: Green Pastures Hospital, Pokhara.
Some 30 patients had been assembled by SM, WB and NB. 20 patients were suitable for surgery. Once again, all patients were assessed on the first day and the week planned. Each day, new patients would appear unannounced and some were included in the theatre programmes. After that, each day consisted of a full day in the operating theatre.
TVB organised theatre procedure and set-up. One nurse (Sushma Bishwakarma) who had been in charge of theatre on previous visits, had left. TVB started new tuition of the three members of the new nursing team (Dipu, Rachhya and Sunita). Stock was taken of instruments and items were replenished/exchanged.
JC, AG and WB once again supervised post operative rehabilitation. As on the surgical side, the focus was on training and teaching. In this regard, Dorothy Das Paryar performed the majority of the splint making and initial rehabilitation under their supervision and showed considerable promise and aptitude, considering the relative novelty of the task. She was left detailed rehabilitation programmes to follow, after our departure. There is tentative plan for Dorothy to spend a Fellowship period in the UK, with AG and DS, in London.
TVB, JC and AG returned to the UK halfway on 28th November. DS and NL 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 week: Kirtipur Hospital, Kathmandu
DS and NL on to Kathmandu. NL connected to her return flight to the UK and DS continued with a solo visit, consisting mainly of teaching in Kirtipur/ Bir Hospital.
The first day: review of assembled patients. 10 patients were selected.
Subsequent days:
Lecturing to some 30 Orthopaedic and Plastic Surgeons from Kirtipur and NAMS (Bir Hospital) and operating on selected cases
The local Hand Surgeons, (SS, LC, BK and others)), received one-to-one training.
Once again kit was delivered to Kirtipur, including a replacement charger for the electric saw/drill/driver set previously kindly donated by DeSoutter Ltd in the UK.
DS returned to the UK on 7th December.
***
OVERALL ASSESSMENT of the various Units
The focus remains on training and mentoring of personnel.
The local surgeons in Lalgadh, Green Pasture and Kirtipur all continue to increase their repertoire and confidence. Lalgadh Hospital has received significant additional input in the form of Dr Jha Sudhanshu (Lalgadh).
The number of operated patients has reduced but virtually each case is a teaching case, with many performed by the local surgeons under tuition by DS. One such case, assisted by a senior surgeon, is worth several performed without guidance. This inevitably prolongs operating time for each case and reduces numbers short term but is far more constructive and sustainable in the long term.
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. 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 is benefitting from the part time appointment of a new Orthopaedic Surgeon, Dr Jha Sudhanshu, based at Sindhuli (some 65 km from Lalgadh). He attends two days a week and will increase the operative volume and scope. He was present, and being taught, throughout our time in Lalgadh. He received the donation of operating magnifying loupes. Dr Krishna Lama is now fully back in his role as lead doctor/medical director.
The plan to organise a visiting team from Kirtipur to Lalgadh at other times of the year (to deal with less specialised cases), has not materialised, largely because of funding issues. It will not be pursued further.
Green Pastures Hospital continues to develop and flourish. The main Plastic and Hand Surgeon, Suraj Maharjan is organised and increasingly expert and confident in running the hand service partly as a result of the ongoing training with DS and these visits.
The Hand Therapy aspect continues to develop under the guidance of Wim Brandsma and the periodic contribution of Jean Cahill and Ann Garewal. The assumption of Dorothy Das Paryar, a new Occupational Hand Therapy trainee, based in the unit, is a good leap forward. There is plan to organise a period of Fellowship and intense tuition for Dorothy in the UK during 2020.
Kirtipur Hospital Hand Unit now consists of Kiran Nakarmi, Shilu Shrestha, Bishal Karki and Lok Chaurasia. All have been taught over many years by DS; Bishal Karki (previously a Fellow in the UK with DS) in particular, has recently returned from a 12 month Microsurgery Fellowship in Taiwan and has brought valuable microsurgery expertise to the Unit, particularly in Hand Trauma, an increasing workload in Kirtipur. Various other members of the Kirtipur team were included in teaching. The Hand Therapy back up in Kirtipur remains excellent with Mohan Dangol and Nhashala Manandhar (both of whom have previously benefitted from Observer Fellowships in the UK).
INNOVATION:
- In all three units, plan has been made to conduct follow up clinic and didactic tuition and tutorials via online video conferencing with DS. This has been set up.
- JC and AG also maintain contact with the local personnel to discuss individual cases and conduct ongoing training online. They have also started collaboration with the nascent Nepali Society for Hand Rehabilitation and Research which is planning the first two seminars during 2020. Links are also being established with the British Association of Hand Therapists, through JC and AG.
- Caroline Leclercq (CL), based in Paris, is an eminent and world renowned Hand Surgeon with a particular interest in Cerebral Palsy. She has collaborated with DS in teaching in many international venues over many years. Her addition to the team on this visit increased the scope and repertoire of our work. There is a great need for surgery for patients with Cerebral Palsy and, provided she is available for the team in November 2020, there is tentative plan to start a new CP service in Green Pastures Hospital. Nola Lloyd, long term member of our team, is currently CL’s Fellow in Paris and is likely, in the future, to contribute significantly to Cerebral Palsy work in Green Pastures if this materialises under CL’s
2020
1.The next visit is planned for October/November 2020 ( we await publication of the festiva.ls to be bypassed). Funding permitting, the team is likely to consist of some 8 personnel, plus Wim Brandsma, who is sponsored by Working Hands to join us from Utrecht.
- Etihad Airlines, which continues to support us very generously, is considering sending one or two of their volunteers on our team on this next visit.
- Dorothy Das Paryar, Occupational Therapy trainee in Green Pastures may be sponsored 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.
- We will consider addition of a brief visit to Sindhuli, 65 km from Lalgadh, to support Dr Jha Sudhanshu, who is based there but also now works part time in Lalgadh.
FUNDING
The two major sponsors of 2019 were:
- Etihad Airlines, which once again provided 8 return flights – the flights remain the single largest potential expense and the provision by Etihad, virtually assures the viability of this project- as well as a generous excess baggage allowance
- The Hilden Charitable Fund which kindly provided the sum of £5000 which defrayed the majority of the trip expenses
- Other significant contributions came from Circle Bath Hospital, AMI Medical (‘One Welbeck’ Clinic), Solent Stevedores, Sarah Byatt
- Too numerous to mention were the smaller contributions, all valuable, very welcome and, taken together, a significant sum.
- Valuable donations or concessions on kit came from DeSoutter and Mercian as in previous years.
- All contributors have been listed amongst the Benefactors on the Working Hands website
Donald Sammut
Bristol 10th December 2019
