Blog SCI Nepal

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Spinal Cord Injury Collaboration, SpiNepal, has crossed a major threshold after six years! Both of our trainees have passed their final examinations (both on the first attempt, a relatively rare occurrence we’ve been told) and are now qualified in their respective areas of specialty, Neurosurgery for Prakash and Physical Medicine and Rehabilitation (PMR) for Raju. While our main objective has been achieved, we DO hope SpiNepal can continue to provide financial support over the next few years for their Continuing Medical Education, fellowships, observerships, etc as they hone sub-specialty skills in the area of spinal cord rehabilitation and spine/spinal cord surgery. We anticipate that some of our funds should be directed at this time to support a rehabilitation medicine training program for which planning is beginning between Dr Raju and the SIRC board. Your donations will continue to be of utmost importance and can be made through this link.  UBC will issue Canadian income tax receipts and can also accept donations from the US (contact us for directions on how to do this).

Sept 17 2017

We spoke at length with Raju and Sheela Sept 16th. He has been busy both clinically and as a medical manager working within the multidisciplinary team (MDT). For example, the SIRC team has had to focus again recently on challenges with wheelchair supply: there is and has been a scarcity of wheelchairs at the centre most of the time. The MDT continues to explore ways to resolve this issue.  (Motivation – a great supporter of SIRC, like Whirlwind in the US, has endeavored to design and provide wheelchairs for those in need worldwide. For those who, like us, did not know much about Motivation UK, we suggest that you watch co-founder David Constantine’s Ted-X talk at https://www.motivation.org.uk/our-story  )

SIRC’s MDT is always working hard to maintain a high level of care for people with SCI with the goal of reduction of complications. Urodynamic assessment (necessary to ensure safe management of bladder function) has now become a routine part of the care program during each patient’s stay at SIRC, following some initial technical problems with the equipment. Colleagues Drs Arjun and Abhishek (two very good physicians, who we met when we were there in May) have left SIRC to explore other training opportunities and Raju is now supervising the two new docs as they learn the essentials of spinal cord medicine. Eventually Raju, Esha and the SIRC board wish to initiate a Rehabilitation Medicine training program and continue to work towards obtaining approval from the necessary authorities.

Raju has been invited to speak about SCI rehab at the fall meeting of the Association of Spine Surgeons of Nepal. His responsibility as medical liaison with acute-care surgeons and services is important to ensure that the core principles of SCI rehabilitation are applied as early as possible after injury.

We learned that there is interest in Injury Prevention in Nepal, with a new project underway. We will provide more details of this program as we learn them from Raju.

We also spoke Sept 16th with Prakash, who has now settled into Greifswald, Germany. His accommodation in Greifswald is good but a little far from his work – a windy 3-4 km bike ride to the clinic. He thinks that the clinic and OR are of high quality. The work day begins at 07:30 with rounds (in German, translated later; the images help). Two Chinese neurosurgeons are also doing the three month fellowship/course with him. His chief travels quite a bit, affecting the volume of cases, but Prakash has established a link with two orthopedic spine surgeons and is taking advantage of this access to learning spine surgical techniques. There is a reasonably-priced cafeteria at the hospital but he plans to cook his own dinners in his ‘home’ kitchen.

We spoke to him in Prague where he had gone for the weekend with his two colleagues. They went by bus as the fare is much better than train; Prakash was impressed with the smoothness of the road compared with those of Nepal!

This week he will be participating in a workshop-based course in his hospital: the “9th Baltic Sea, International Hands-On Course on Full HD Endoscopic Neurosurgery” organized by his supervisor Dr Henry W. S. Schroeder. You can find more details of this course at: http://ifneuroendoscopy.org/wp-content/uploads/2016/11/Flyer-Baltic-Sea-2017.pdf

Sept 6 2017

Raju has, after only a couple of months in his new position, exceeded our expectations as he assumes a number of administrative responsibilities, and has already been recognized for his role in shaping Nepal’s support for people with a disability.

He was recently interviewed for the Nepalese online medical magazine “Hello Doctor” providing an explanation of the need for an integrated system of care for those with SCI including prevention and prehospital care, acute care, rehabilitation and community reintegration. He also discussed the ideal referral system which includes a medical data system which can coordinate care and research. If you would like to watch it, be aware that it is 95% Nepalese: https://www.youtube.com/watch?v=6uRJrYvn0FE

Raju was a panelist (left) in Nepal’s first National review and planning workshop on disability, developing a disability action plan.

He is the first person to receive the Keshabati Maskey Disability Excellent Service prize (right).  This award is given by the Nepal Association for the Blind, an organization that also supports those with other causes of disability. A Felicitation ceremony recognized his significant contribution enhancing awareness of the needs of people with disabilities for a productive life, their rights and dignity, treatment and rehabilitation – and received a cash award. (Keshabati Maskey was a UN official, had a SCI during diving for which she was treated in the UK.)

 

Meanwhile, Prakash was in Barcelona this week presenting a poster on the management of epilepsy in Nepal (left). He and his team (right) visited the Guttmann Institute, a large neurorehabilitation hospital inaugurated 52 years ago following the principles of Sir Ludwig Guttmann.(Right: Guttmann Institute host Dr Jesus Benito Penalva on the left, Kathmandu neurosurgeon Dr Hemav Rajbhandari far right.)  We look forward to hearing their impressions of the work done there.

Prakash also had time to visit the Sagrada Familia cathedral and enjoy paella with a Nepalese friend now living in Spain. From Barcelona, Prakash flies today to Berlin and then (by train) to Greifswald in northern Germany for his three month neuroendoscopy fellowship.

 

Aug 27 2017

Today’s good news is from Dr Prakash – he just heard that he has won the first newly given gold medal awarded for the highest marks earned on the first attempt in the 2016 Pakistani neurosurgical fellowship. We are all proud! When we spoke today, Laxmi was at work and Prakash was playing with Ritika (left). With his visa now in hand, Prakash leaves in another week for Barcelona for an epilepsy conference before going to Greifswald (see below).

June 20 2017

News from Nepal: an email from Dr Raju (right) describes him settling into his new life back in Kathmandu and work as the Medical Director at SIRC – we look forward to more detail when talking with him again soon. He and his family are looking for new accommodation as he and Sheela are expecting a baby in October or November, so, with new clinical and administrative responsibilities, life is busy for him. We have also been discussing how he can most easily travel to work each day in a way that is time efficient and that lets him work as he travels.

Meanwhile, Prakash is planning a three-month “mini-fellowship” in Neuroendoscopy in Greifswald, northern Germany, this fall. The position is funded by the host but these funds will likely not cover all costs, so he will need a small subsidy from Spine Nepal.

We just received from SIRC links to an interesting video from the World Health Organisation regarding the role of rehabilitation after major disasters. Not surprisingly, SIRC features quite prominently in this, beginning with the opening scene shot soon after the earthquake.  The YouTube description reads:

Emergencies, particularly sudden-onset disasters, can result in a surge of traumatic injuries that strain health systems and leave a legacy of disability in their wake. Responding to the needs of the people affected can be challenging in settings with limited health and rehabilitation infrastructure, where many emergencies occur. To address this, WHO together with health partners such as CBM, Handicap International, and the International Committee of the Red Cross, released the ‘Emergency Medical Teams: Minimum Technical Standards and Recommendations for Rehabilitation’ which provides important guidance on how emergency medical teams (EMTs) can incorporate rehabilitation in their response to emergencies. Using the experiences from the 2015 Nepal earthquake, this video shows the impact it had on the lives of those injured years later and highlights the reasons why rehabilitation needs to be a core component of any emergency medical response. Integrating rehabilitation into the EMT response resulted in greater clinical care by producing important, cost-effective, and positive long term outcomes at the individual, family, and community levels.

Those interested in more reading material can find further material here:

WHO Emergency Medical Team initiative:   https://extranet.who.int/emt/sites/default/files/EMT_Updatednews_19.01.2017.pdf

WHO Foreign Medical Team guidelines: http://www.who.int/hac/global_health_cluster/fmt_guidelines_september2013.pdf

May 24 2017

We were pleased with our visit to Nepal. SIRC continues to grow despite challenges and, as yet, lack of a sustaining income from the government. It’s programs are carefully thought through and it has become a very creditable rehabilitation centre.

What did we find at SIRC?

  • An expanded physical plant. There is a new vocational training building to support programs bringing in 30 patients at a time for job training. A new array of solar panels has been added to the roof; one array is dedicated to warming one ward through newly installed underfloor pipes, much needed for those patients whose temperature control is impaired.
  • Two very good doctors. Dr Arjun and Abhishek (picture below right) are careful and dedicated and both see a future in the different aspects of care of patients needing neurorehabilitation. Dr Christine (a physiatrist) continues to act as a consultant and mentor. We had often corresponded with Christine and had ‘met’ her on Skype, but this was our first time face to face – we were impressed.
  • Full beds – there were patients in 51 of the 53 acute rehab beds. The (n1) beds put in place for the ‘surge’ after the earthquake have been used for the vocational program. Now that the new vocational building is available, (n2) beds will be dedicated to the new stroke program. Patients will be considered for admission to this once full staff training is complete.
  • Improving skills in managing the paralyzed bladder.  
  • The new urodynamic equipment unfortunately needs significant servicing (including sensor replacement), and minor changes are also needed to the space available. Weekly ward rounds are made with a urologist (right).

 

  • Pressure sores continue to be a challenge, as they are in all spinal injury units. Team discussions during our stay (right) focused on the problems getting reliable data about the prevention and care of PSs once the patient is back in the community. Deaths have been associated with pressure sores but the cause of death is often not accurately recorded and the team needs to have reliable data on each patient if effective changes are to be made in patient education.
  • A new and amazing vocational program developed with the support and encouragement of the South Korean government and Korean spinal injury association. The new building which will support this was inaugurated just after we left.
  • Solid administrative support from a number of very competent people, with a new operations manager who also impressed us with his understanding of the clinical issues.
  • Your generous donations supported Raju’s month-long training in spinal cord medicine at the Swiss Paraplegic Centre (SPZ) in Nottwil. He returned to Kathmandu brimming with enthusiasm and new knowledge. Five other SIRC staff spent the month there as well, and it was rewarding to sense the tremendous energy engendered in all of them by the trip. The team(s) from SPZ have consistently provided support and teaching over the years, and we share the gratitude of our Nepalese colleagues for the opportunity they were given this year.
  • New exploration of mobility options – SIRC is working with the local university to explore the feasibility of local manufacture of suitable wheelchairs. We wish them luck with this initiative.

We had a number of meetings at SIRC, reviewing ongoing needs for Drs Raju and Prakash as they work through plans for their careers and those of the patients for whom they care. PM&R training is planned for Nepal and SIRC is well positioned to aid this planning with Dr Raju and his good regional network of connections. The Board is certainly solidly committed to training in the field of PM&R.

  

Left: Dr Raju reviews lessons learned in Switzerland with Dr Christine

Right: Breakfast with Raju, Sheela, and the team returning from Switzerland 

 

May 5 2017  (Kathmandu)

Dear friends and supporters,

We (Claire and Peter, travelling with supporters and friends Dave and Darby) reached Kathmandu Friday a week ago after four days in Hong Kong to explore and to successfully get over jet lag. We were met by Dr Prakash and taken by minibus to the Happiness Guest House near Boudha (pictured above), the Tibetan area of Kathmandu that is walking distance to the Nepal Orthopaedic Hospital in Jorpati (where SIRC begans its life 15 years ago) and to Raju’s family. The post-earthquake tent city ironically near the Hyatt Hotel had just disappeared; new buildings were in evidence; the major road to Boudha and Jorpati was being widened by the partial demolition of buildings beyond their legal footprint, and city water from the distant Melamchi River was being piped into the city so that the potholes were much worse than usual as the water mains were buried under the road. Kathmandu was preparing for its first municipal election in 20 years in a few days. Over the weekend we were able to spend time with Raju and Sheela (expecting their firstborn in a few months) and Prakash, Laxmi and a very lively 19-month old Ritika (right).

We planned to make the trip now to synchronize with Dr Raju’s return to SIRC and our major goal for the trip was to offer mentorship and a ‘sounding board’ on his early return to a very different role than he had before. Further, we had spoken with Dr Christine (seen left with new Admin Director Sanjeeb) who has been a great mentor to the two junior physicians (Drs Arjun and Abhishek) who are providing routine clinical care. We had not yet met Christine face to face but from all we had heard knew that she would be a great support to Raju also.

Raju’s news: His training has concluded with the successful completion and defence of his thesis (comparing two conservative treatments for low back pain). He now has his MD specialty qualification in Physical Medicine and Rehabilitation.  A big “Thank You” is due to the BSMMU faculty for having the faith to accept him and to train him over the last five years. Part of Raju’s training has been attending conferences and visiting other centres – these have included: the Irish National SCI Centre, the Indian Spinal Injury Centre and rehabilitation training centres in Melbourne, Toronto and Vancouver, the latter in association with attendance at the PM and R review course in Toronto. A further wonderful opportunity (and a logistical challenge) presented itself a few days before we left for Nepal, when we learned that the SCI team was to leave on April 29th for Switzerland as guests of the Swiss Paraplegic Centre (the SPZ) in Nottwil. As these are the people that Raju will be working closely with, this clearly presented a real opportunity for him to work closely with his colleagues in a stimulating learning experience. Thanks to our supporters, we had sufficient funds in hand to cover his expenses in joining them. Our Swiss colleagues were supportive, and the Swiss embassy here was extremely efficient in providing a visa within days so that Raju left May 2 for Zurich to join his colleagues from SIRC. An interesting additional note: a newly formed international Cochrane Rehabilitation was launched December 2016 to which Raju was invited to participate to represent his region. 

Unable to attend the ISPRM meeting in Argentina at which the group was to first meet in person, he rose at 2:30 am May 2 to join a conference call with the group, prior to heading to the airport in Kathmandu. For news from Switzerland, watch your Facebook pages – thanks to the team for these pictures!

Prakash news: Prakash has been continuing his active neurosurgical work at Bir Hospital, although he is still on a ‘daily’ casual employment basis and looks forward to sometime in the future when he may become a staff member. In the meantime he has had a poster on epilepsy treatment in Nepal accepted for an international meeting in Barcelona this September and been awarded partial support to attend that meeting. This may also link in with a three month neuroendoscopy training course in Germany that he is considering attending. Congratulations, Prakash! He invited the four of us to join a number of his neurosurgical mentors and his former general surgical chief at a favourite restaurant (the Alice) last evening – a delightful way to celebrate completion of his neurosurgical training. To complement this – we had a spectacular lightning display over Kathmandu and the foothills of the Himalayas to the north of us.

As of the end of April the major training phase has thus been completed and both doctors cease income support from Spine Nepal. However, there are “bridging” needs that we are currently exploring and will discuss in more detail on return home. For Dr Raju, we are supporting the costs of the current course at SPZ. For Dr Prakash, there may be some assistance to support his application for a one-year spine surgery fellowship (which should be self-funding), the place yet to be determined, to qualify him to pursue a spine surgery practice at an academic level on return home.

May 3rd was like the old days for us. We were up early and walked through the Boudha stupa area, where hundreds of people walk quietly around the majestic structure, murmuring, working rosaries, spinning prayer wheels. We had a ten minute wait to watch the bustle on the Jorpati road, then it was on to the big yellow bus for the one-hour ride to SIRC. We met Sanjeeb, the new Administrative Director (read: COO) and talked with many old friends. P spoke with Prajjwal, formerly the Community Based Rehab worker visiting homes and arranging necessary modifications. He is now a manager with VOICE, a vocational training program, of which more later. A brief breakfast was taken then Claire and Darby joined the three MDs for rounds (below).

Peter and David walked around the hospital. Things that impressed us:

Completion of the upper level. This facility expansion sponsored by MSF Belgium now houses offices and part of the vocational training program – the area where machine sewing skills are taught. The former SIRC patients come back to SIRC for three months and learn a number of skills: sewing, pickle making and canning, or English and IT skills.

Downstairs one major change was seen: underfloor heating has been installed as a pilot project in one ward. Weather and indoor temperatures will be monitored to assess the effectiveness of the solar water-heating panels. As it is, the expanded solar water heating (below) and photovoltaic panels installed on the hospital  have reduced the monthly cost of electric power for the hospital from about 100,000NR to 30,000NR (1 CAD = 75 NR).

The physio and OT areas were busier than we have ever seen them, and we hope that this work is charted on an integrated chart to ensure that the treatment plan and its progress is quickly available to other care team members .

SIRC is preparing to accept stroke patients for rehab, capitalizing on the earthquake expansion of capacity. Not all team members are yet fully trained and ready for this step but the date is nearing when this will take place.

The therapy pool (suited for selected SCI and stroke patients) temperature is not yet high enough for these patients whose temperature control may be impaired, and facility modifications to correct this are planned.

The VOICE program is a bold vocational training program being undertaken with the support of the Korea International Cooperation Agency of the South Korean government and the Korea SCI Association. We hope to learn more about this today.

Ram, one of the five peer mentors at SIRC, is planning a new yatra throughout Asia to enhance awareness of SCI. He plays the sarangi (left), and now has a musical ballad on YouTube that tells his story in a very Nepalese way, but with English subtitles : https://youtu.be/fE4hBBnSyIE

We (possibly joined by Prakash) will be out at SIRC again today to meet with CEO Esha, to learn more about the exciting changes, and to join Drs Arjun, Abhisek and Christine in a teaching session this afternoon. Then, dear friends, we depart Sunday for Pokhara and a trek to the Mardi Himal and Ghorepani areas, Age-Related-Symptoms permitting. We return after that for another week in Kathmandu before heading back to Canada.

 

April 8 2017 

Raju has successfully completed his Physical Medicine and Rehabilitation training and, apart from attending to the paperwork, has one more step to go: please joining us in saying “Good luck” to him for success with his final hurdle – defense of his research thesis April 15 (News Flash – he was successful!! 😀 ). Then it will be time for Raju and Sheela to pack up for the last time and prepare to move home to Kathmandu. There will be practical issues to sort out as he joins the SIRC staff again, this time with clinical and administrative responsibilities as the senior physician and only physiatrist (trained rehabilitation specialist) practicing in Nepal. He is looking forward to working with the patients, with administration, the care team and, of course with the two staff doctors there. Volunteer physiatrist Dr Christine Groves will be a wonderful mentor for Raju at this stage. Unfortunately, the details of his employment have not yet been addressed and will keep him busy when he first returns, as well as addressing the practical issues of how to organize his work week, where to live, how to commute etc. Meanwhile, Prakash has been working steadily at the Bir teaching hospital with Dr Prakash Bista, his teacher. He has been enhancing his surgical skills, is considering a couple of research projects, and will probably be seeking a position at some future time as a spine surgery fellow, the usual ‘next step’ for an orthopedic or neurosurgical spine surgeon.

SIRC has been marking its 15th anniversary this week with a celebration, parts of which are described in Kate Coffey’s blog, while you can also find a photographic record of the ceremonies through the Facebook page.  Here, you see some of the attendees at the SIRC ceremonies outside the facility. (photos courtesy of SIRC, Maggie Muldoon and others)

Left: CEO Esha Thapa with Founding Chair Kanak Mani Dixit, board member Anil Bahadur Shrestha and supporter Goma Dulal. Right: Esha, Christine, Chanda, Mandira and Sonika

Claire and Peter leave for Nepal on April 23rd. We shall travel with long-term supporters and good friends Dave and Darby. We plan to spend a few days in Hong Kong to help us get over the jet lag associated with the 12 hour time change, arriving in Kathmandu April 28. We expect to spend two weeks working with Raju and Prakash and trek for about a week – the details of what we can most usefully do with respect to our trainees have yet to be determined.

One of our tasks will be to say a big thank-you to SIRC founding chair Kanak Mani Dixit and his fellow-board members as well as others in Kathmandu who have contributed to the development of SIRC. We are still working out how to do this as Kanak can be very busy. Interestingly, Kanak will be speaking in Berkeley on May 8th: more about that here.

Kanak remains very politically active through his work as a writer and blogger – our thanks to him for drawing our attention to the Madhesi Youth Photo Project by Puru Shah here. (The Madhesi are the inhabitants of Nepal’s low-lying Terai region.) You may also be interested to look at some of Puru’s other work: the unhappy story of a Nepali work migrant’s problems in Saudi Arabia here and an excellent infographic about migration patterns in/from Nepal here – this is excellent use of interactive graphics following the stylistic approach of Gapminder – founder Hans Rosling would have been delighted to see this work.

On return from Nepal and in consultation with our colleagues in Nepal, Canada and elsewhere we hope to bring all our supporters up to date with the ongoing Spine Nepal plans for support of spinal care in Nepal.

Feb 20 2017

Another major goal achieved: Congratulations to Raju on passing his final examination on the first try. He now has an MD degree in Physical Medicine and Rehabilitation. He must still complete his dissertation and anticipates that the defense examination will be complete by April. He will stay in Dhaka until then, most likely, and expects to participate in an ultrasound course. In the meantime he will attend regular rounds and academic sessions at the hospital. He expects to be back in Kathmandu around the middle of April, perhaps missing the 15th anniversary of the SIRC (see below).

Raju and Sheela plan to sell some of their small collection of furniture; the rest will be given away. Packing and planning for the return home begins now – he has amassed a number of books he needs to take home. Raju has sent a brief note of relief to us all which you can read here.

Claire and Peter were hoping to attend the 15th anniversary celebrations, but the priority is for us to be there as Raju begins work in his new position as Medical Director of SIRC, so we now expect to travel a little later – perhaps early May.

Raju’s wife Sheela, meantime, is looking for other work opportunities to take effect when she is back in Nepal – she obtained her Master’s of Public Health degree in Dhaka.

Prakash has renewed his contract renewed as a junior neurosurgeon for another 6 mos at Bir teaching hospital in Kathmandu; he is performing an increasing number of spine cases and has recently submitted a case report for consideration for publication. From time to time he discusses details of case management with Scott and/or Peter. The requirements to enter employment in a Nepalese government hospital are quite strict so he may look for opportunities in another situation such as the Kathmandu Model Hospital. He is interested in completing a spine surgery fellowship first and is seeking opportunities for this. On the home front, little Ritika is now walking and chattering away.

We lost a great man this week – you may be interested to learn about him. He was a renowned Swedish public health physician: Dr Hans Rosling, who succumbed to cancer at the age of 68. We have heard him speak a number of times on the subject of world health using United Nations/World Health Organization data which he presents most eloquently using specific software developed through the Gapminder Foundation.  If you have not heard him speak, spend an hour or so on one or both of these videos:

https://www.gapminder.org/videos/dont-panic-end-poverty/

https://www.gapminder.org/videos/dont-panic-the-facts-about-population/

….after which you may wish to check out his TED talks, or to download the Gapminder software and enjoy manipulating the data yourself.

Finally, SIRC celebrates its 15th anniversary April 6-8. Follow their plans as they become available here. We hope to report on it in due course.

Dec 29 2016

Looking back at the end of last year:

Dear friends and supporters – it has been a quieter year and a year of ongoing recovery for our colleagues in Nepal. SIRC has been working on the development of a stroke service and we look forward to learning more about that on our next visit.  Our two young specialists-in-training are a bit closer to their target. Dr Prakash passed his neurosurgical specialty exams in Pakistan this year, is now working at a junior level in the Bir Hospital in Kathmandu, and considering his options for further training in the spine surgery area. Dr Raju has further work to do on his research project and will in mid-January be taking his final clinical exams; if all goes well he will return to Nepal to work in SIRC at the beginning of April, as SIRC celebrates 15 years of providing service to those with SCI. We hope to return at that time.

2016 will soon be over: the year end is upon us, and if you have not decided how to direct your tax-deductible charitable donations this year, please keep this project in mind. As our goals of providing training to two doctors near completion we will work with colleagues on a longer term plan. We invite questions by email through the contact link above.

Other countries also have much work to do for those with SCI and we bring you here a couple of news items from Africa: In many African countries the situation for those with SCI is similar to Nepal, but new units have been developing, notably with the help of our friends at the Spinalis unit in Stockholm. Check out this short video which is a brief vignette of the SCI rehab unit set up in Gaborone by the Spinalis team from Sweden working with their colleagues in Botswana. Swedish TV has developed a longer video about this project and we hope that will become available in due course. And, read this recent Guardian article about two developments in Kenya – be sure to follow the links to see the developer’s ingenious power wheelchair prototype in action.

Thanks for following our progress. We wish you a Happy New Year – may it bring you happiness and fulfilment!

Peter and Claire