BFIRST Visit to Nepal 2023
In April and May 2023, Ms Sarah Tucker, Mr Conrad Harrison and Mr David Izadi visited Pokhara, Kathmandu and Kirtipur.
Green Pastures Hospital,Pokhara
Green Pastures Hospital (GP) is a 40-bed hospital set up by the International Nepal Fellowship NGO which is celebrating 70 years or work in Nepal this year. It is primarily a rehabilitation hospital for people living with disability including spinal injury and leprosy-related impairment.
Current services include:
- Walk-in dermatology (and leprosy screening) clinic
- Occupational therapy (3 out of the 9 occupational therapists working in Nepal are at GP)
- Physiotherapy, including spinal rehabilitation and hand therapy
- Rehabilitation medicine
- A specialist ear centre
- Palliative care
- Plastic and reconstructive surgery
Under a new medical director, Arun Budha, the team at GP have plans to extend their scope to both the treatment and prevention of long-term disability through early intervention. They have ambitions to take on more acute and trauma work but have not secured funding for this yet.
GP now has two plastic surgeons, Suraj Maharajan and a junior fellow working under him. Suraj feels he has benefitted from his IFSSH fellowship and Oxford-based clinical observership. He is taking on more complex cases, with increasing confidence and clarity in his decision making.
We delivered 2 large bags of dressings and splints, and supported Suraj through three cases:
- A posterior thigh flap for ischial pressure ulcer reconstruction
- Excision of a vascular malformation in the thumb of a child, followed by a local flap reconstruction
- Excision of a large neurofibroma from a foot
Suraj and Arun expressed appreciation for our visit. They feel they would benefit from future BFIRST visits to GP as well as remote discussion of complex cases.
Western Regional (Gandaki) Hospital, Pokhara
Western Regional is a government-run hospital with 500 beds and an academy that is training doctors and nurses. The chief medical superintendent is Bharat Khatri, an orthopaedic surgeon who worked alongside Sarah Tucker for 2 years and understands the value of developing a plastic surgery service. He has recently helped to appoint a plastic surgeon, Piyush Giri, with the aim of developing a plastic surgery service.
Piyush trained with the team at Kirtipur and has recently started practising as a consultant. He is a confident surgeon and is performing complex operations, including replantation and free-flap head and neck reconstruction.
Bharat would be able to arrange temporary registration for visiting senior surgeons as ‘visiting Professors’ in exchange for some input at the academy such as lectures or a day’s course for interns.
Suraj and Piyush know one another but are not in regular contact. We have encouraged them to liaise together about interesting and complex cases.
National Trauma Center (NTC), Kathmandu
The NTC is a 200-bed specialist trauma centre in Kathmandu with services including orthopaedics, general surgery, neurosurgery, ENT, cardiothoracics and vascular surgery. We were invited to deliver a half-day of regional teaching at the NTC which was well-received. We gave talks on upper limb spasticity, orthoplastic collaboration and evidence-based practice.
Shilu Shrestha, former IFSSH fellow and now the only female orthopaedic surgeon in Nepal (out of 600), is running a hand surgery service at the NTC which primarily focuses on acute hand trauma, but also includes brachial plexus surgery. She has a team of residents training under her.
Shilu has requested that we visit her on subsequent trips. She feels that she and her residents would benefit from BFIRST support. In the meantime, she has requested remote teaching for her residents over the next year in both clinical and academic surgery.
Nepal Cleft and Burns Center (Kirtipur Hospital)
The 100-bed Kirtipur Hospital is located just outside of Kathmandu city and has the largest Plastic Surgery unit in Nepal. This is where BFIRST has mainly concentrated its input to date.
Two surgeons at Kirtipur have completed global fellowships and are now consultants:
- Bishal Kharki spent a year practising microsurgery in Taiwan
- Manish Yadav spent 3 months practising burns in Mumbai
The team are very capable, carrying out complex cases including advanced microsurgery. At Kirtipur, we supported the team through 2 all-day cases:
- A free latissimus dorsi flap for a scalp avulsion injury
- Forearm reconstruction including bone grafting and tendon transfers
We had planned to support with a revision free flap but had to abandon this case due to infection.
One of the new consultants, Kamal Pathak, will be visiting the UK at some point in the autumn/winter for a 6-week, BFIRST-sponsored, cleft and craniofacial fellowship in Newcastle. We have offered to also host him in Oxford for a week during his time in the UK.
Potential future plans
The plastic surgery services at GP and Gandaki are less developed than Kirtipur and would benefit from regular visits in future. This might include teaching at the academy under visiting professorships. We will continue to discuss cases with Suraj remotely and encourage Suraj and Piyush to discuss cases with each other.
We will aim to visit the NTC during our next trip and possibly deliver a short course for residents there. In the meantime, we will work with Shilu to arrange online teaching for her residents.
We will continue to discuss complex cases remotely with the Kirtipur team. We will focus on complex decision making next time we visit Kirtipur, and start to reduce the time spent there to allow more time for the surgeons in Pokhara and the NTC.
We will aim to set up Proximie for support at Kirtipur initially. Kamal’s visit to Oxford may be an opportunity to train a member of their team in the use of the software and hardware.