Projects
Zambia
Planning is underway for a BFIRST project to Zambia. We will keep you updated!
The LION, Malawi
Mr Tony Barabas visited the LION in Malawi earlier this month, here is his report:
 
The Lilongwe Institute for Orthopaedics and Neurosurgery (LION) 2023 vs 2025.
The improvement in conditions in Malawi in general, and the orthopaedic department in particular, is quite remarkable over the last two years since I last visited in 2023. Much attention to infrastructure building around the capital Lilongwe, has resulted in greatly improved transportation links. For the orthopaedic department, the move from the old Kamuzu Central Hospital into the LION Hospital (Lilongwe Institute of Orthopaedics and Neurosurgery) has transformed the care of Trauma and Orthopaedics in the country. The hospital is well constructed with a clean, open Scandinavian design and feels spacious. The wards, although less crowded still do have problems with capacity. This will hopefully be improved with the opening of the new children and women’s wing in a few years’ time. Currently women reside in two of the eight ward areas, and children are still located across at Kamuzu Central Hospital.
  
Hand anatomy teaching and Tony Barabas in full flow.
With theatre capacity having doubled the number of procedures performed has also significantly increased, and the operating hours are much better regulated. There are still problems with patients being prepared for theatre in a timely fashion with ongoing problems in ordering bloods and other investigations. Imminent implementation of an electronic patient record should help to improve this.
Dr Precious Kachitsa, Hand Fellow at the LION
From the point of view of Hand surgery the conditions for both patients and staff working in hand surgery have improved immensely. The outpatient clinic space is clean and tidy, and although still far from spacious, the ability to properly examine, dress, splint or refer to Hand Therapy has improved significantly as the dressing clinic, Plaster Room and Hand Therapy are all located adjacent to the hand clinic. The protected operating lists on a Tuesday and Thursday in the emergency department Theatre allows local, WALANT, and even brachial block cases to be performed in a clean and well maintained environment.
Unfortunately the mini C-arm no longer takes x-ray pictures and requires servicing, which can only next happen when the Vertec rep called Fatsani visits from South Africa to service other equipment in the x-ray department. This is limiting the amount of fracture fixation which can be performed in the A&E theatre.
Nurse Emily, A&E sister in charge, cleaning up after surgery.
Wednesday is the allocated main theatre slot for Hand surgery, and the availability of anaesthetists who can quick and skilfully provide excellent brachial blocks both increases the turnover of cases and the safety procedures. Most cases requiring complex fracture fixation must now be performed on a Wednesday. The provision of instruments and the correct sorting of sets has much improved, although vascular repair instruments are lacking but the BSSH LION team are already looking into sourcing vascular sets.
 
Upgrades to the outside of the hospital and the clinic.
I again visited during the maize harvest season and as a result panga injuries were the most prevalent type of injury. With 2025 being an election year, and with motorbikes provided as an incentive to vote for certain parties, injuries from motorbikes or reported as being on the increase.
  
The Minor operations theatre has been updated, Dr Kachitsa scrubbing in, and Mr Barabas with a patient (consent obtained)
With a changeover in residents before I arrived, knowledge of basic hand anatomy and assessment of hand injuries was very poor, and within the regular training program this needs repeating regularly with each new intake of doctors.
The overall direction of travel is very positive. I discussed with both Sven Young (CEO) and Boston Munthali (medical director) my impressions. It is a predominantly positive outlook, but greater provision for plastic surgery reconstructive options is still necessary, particularly for lower limb injury patients. I also feel more attention to basic training of juniors in a structured fashion could be implemented. The nursing staff have directly asked me for nursing input and attention to patient pathways and control of the ward environment would also significantly help managing patient pathways through the LION hospital. These are areas both the BSSH and BFIRST should consider helping with in the future. My goal is to change the “O” in LION from “Orthopaedics” to “Orthoplastics”!
Nepal
In March 2025, BFIRST returned to Nepal.
From left to right: Conrad Harrison (plastic surgery registrar), David Izadi (consultant plastic surgeon), Sarah Tucker (consultant plastic surgeon and project lead), Yanni Tse (senior hand therapist), Anychia Ramracheya (senior hand therapist)
We were delighted to be joined by our hand therapy colleagues for the first time this year – this allowed us to address some critical areas of unmet need and build on our working relationships with local physiotherapy and occupational therapy teams.
We visited four teams across two cities:
Sunrise over the Annapurna Mountain range
Pokhara is a picturesque city known for its stunning natural beauty, serene atmosphere and resilient community. Surrounded by the majestic Annapurna Mountain range and dotted with tranquil lakes, Pokhara offers a perfect blend of adventure and peace. However, the local communities see the vast effects of leprosy and burns.
Here we visited our dear friend and colleague Dr Suraj Maharajan and his team at Green Pastures Hospital. Green Pastures is a small hospital that cares for patients with long-term conditions including paralysis related to leprosy and disabling burns scars. We were able to share common hand therapy protocols with the team and support Dr Suraj in some complex surgeries.
Yanni Tse and Anychia Ramracheya with the Green Pastures Team
At Green Pastures Hospital there are established occupational therapy neuro and paediatric treatment areas, a Safe Farming Field, and a cooking simulating area. We spent time with the local occupational therapist (Sudip). Being the only occupational therapist on site, Sudip has stretched himself across all fields of Occupational Therapy, with assistants carrying out some routine therapy sessions, leaving him with little time to spend on complex hand therapy cases. Having said that, Green Pastures has a well-set designated hand therapy room with a donated splinting pan, and plaster of paris/other consumables, however there are limited splinting supplies. We saw patients with finger amputations, nerve repairs, nerve injuries, flexor tendon repairs, and repetitive strain injuries. We were able to provide training on protocols for flexor tendon and extensor tendon injuries, scar management, treating the stiff hand, and nerve assessment and treatment.
Yanni Tse in the workshop demonstrating splinting
Also in Pokhara, we visited surgeons and senior leaders at the busy Gandaki Western Regional Hospital, where we discussed collaborative working, established ties to their therapy department, and delivered lectures on orthoplastic reconstruction, clinical research, and hand therapy.
The hand therapists then spent some time with the physiotherapists in their department. There is one permanent physiotherapist and two trainee hand therapists who spend about 6 months at Gandaki before rotating out. There are no supplies for splinting, and so patients are usually referred for movement and exercise after being immobilized in post operative dressings or being fitted with POP casts.
They see a whopping 40+ patients per day, with a vast array of conditions. There was a definite consensus to share hand therapy protocols and patient information exercise leaflets with the team, to provide more efficient hand therapy.
THE BFIRST team in front of the Kirtipur Hospital and an outrigger splint for extensor tenson injuries.
In Kathmandu, Nepal’s capital city, we met the team at Kirtipur Hospital (a national cleft and burns centre, long partnered with BFIRST). Kirtipur is a historic town located on the outskirts of Kathmandu. Known for its rich cultural heritage, Kirtipur is one of the oldest settlements in the Kathmandu Valley. With its hilly landscape, ancient temples, and traditional Newar architecture, the town offers a glimpse into Nepal’s past.
Dr Shilu Shrestha and members of the surgical faculty with the BFIRST team at the Major Trauma Centre in Kathmandu
While we now have little to offer the highly skilled team at Kirtipur, we were excited to explore the possibility of hosting international fellows at Kirtipur in future years. The team are particularly well-positioned to teach burns, cleft, hand and microsurgery to fellows visiting from low-middle income countries. The Kirtipur team expressed gratitude for surgical and therapy teaching sessions that we put on during our time there.
Anychia Ramracheya talking about rehabilitation programmes
The therapy team were able to join the local therapy team in assessing and treating patients with severe burns, congenital hand conditions, tendon repairs, nerve repairs, degloving injuries and chronic stiffness, and made use of handy thermoplastic scar management tools.
There is a great opportunity for the surgeons and therapists to have better referring systems including surgery details and dates, complications, follow ups and specific requests or possible outcomes. We found that the therapists make use of an immobilization or delayed mobilization protocols. This led us to provide extensive one on one training with the therapists and surgeons on extensor and flexor tendon protocols and the benefits of early mobilization. We also found that there is a need for training on fabrication of custom-made pressure garments for burns patients and offered training on this in a future visit, to which the therapists have responded keenly!
Yanni Tse and her hand fracture rehabilitation talk, and pictures from the workshop on splinting
We were then able to spend more time with Dr Shilu Shrestha at the National Trauma Centre, Kathmandu. We delivered a whole day of teaching on hand surgery, therapy, research and quality improvement infrastructure, and orthoplastic principals. Our focuses here were on:
- Preventing avoidable hand stiffness – our hand therapists were able to deliver teaching and care across two hospital sites, and with the help of some visiting medical students we have started a system for routine data capture that will help the team to target future service improvements.
- Orthoplastic reconstruction – we were able to support the team through some complex surgeries and lay foundations for future expansion in this area.
The hand therapy teaching was directed towards the post-operative care of flexor and extensor tendon injuries, managing fractures, and preventing and treating the stiff hand, which was pitched to surgeons, therapists and students and aimed to show the importance of good communication between the therapist and the referring doctors.
Building relationships with our hosts over a traditional meal
As always, we will be staying in contact with our colleagues in Nepal throughout the year and cannot wait to visit again in 2026!
Addis Ababa, Ethiopia
From left to right: Dr Yenealem, Dr Wolde, Dr Abraham, Mr Barabas, Dr Gobe and Dr Aboye.
Mr Tony Barabas visited Dr Abraham at the Department of Plastic Surgery at the ALERT Hospital in Addis Ababa, Ethiopia, where BFIRST donated optical training microscopes, which will go to Ethiopian and COSECSA plastics trainees, along with the four final year trainees hoping to attend the Ganga micro course. BFIRST is in the process of setting up training courses in microsurgery with the help of Miss Rebecca Shirley and Mr James Chan.
From left to right: Dr Amanuel Tebikew (2025 BFIRST fellow), Dr Martaha, Dr Meti and Mr Barabas
He also visited Dr Meti at St Paul’s Hospital, Addis Ababa, where a training microscope will be located and future cadaveric training courses established.
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