On the 15th of November the first meeting took place between the staff of Nepal Cleft and Burn Centre (Kirtipur Hospital) and us. Wim Brandsma introduced us to Dr Kiran Nakarmi and Mohan Dangol who respectively work as a plastic hand surgeon and hand therapist. At that meeting we decided on the program for the coming days.
We felt a warm welcome in the Kirtipur Hospital where we spent four days. Kirtipur is located on a hillside at the edge of Kathmandu. The hospital is a modern and large building with 32 clinical beds on the burn unit and 10 beds on the Intensive Care Unit especially for burns. Dr Shankar Rai is director of the Kirtipur Hospital and works as a plastic surgeon. The health care is provided to people of all backgrounds and paid for with funds from donations. The cafetaria provides a little extra income to support special needs of the hospital. In the kitchen bio gas is used, as a part of the total ecological vision of the hospital.
The burn and hand rehabilitation consists of clinical therapy and out patient care in a well equipped therapy room. They are for example able to use thermoplastics, velcro, splint pan, heat gun, Tubigrip, Coban, Jamar, Semmes Weinstein test, goniometers and exercise material for adults and children. Nhashala Manandhar is a physical therapist who has joined Mohan recently.
Monika Pokhrel –a former hand therapist in Kirtipur- joined us for a day. For our visit 30 out patients were specially invited to discuss the therapy options with us. This meant that we were able to start straight away. For each patient we tried to stimulate clinical reasoning, specifically about burns, tendon injuries, nerve lesions andstiffness. The splinting skills are good and we highlighted the importance of active motion in all these cases. We offered advice about the possibilities for scar management. At the moment there are no silicon applications or custom made pressure garments available, instead Tubigrip is used. They had already started to keep patient records about the therapy interventions and we discussed possibilities for documenting findings. In addition to patient related topics we discussed the validated use of the Semmes Weinstein test.
The next day the therapists were able to assess the sensibility of a patient with it. For the future soft cast might be an option with easier transport to Nepal than thermoplastics. We practised applying a wrist splint with the soft cast. Apart from the out patients, we saw many burn cases clinically. Postoperative positioning of the hand as contracture prevention was an important topic. We provided information about the way of applying dressings and enabling mobilisation of the hand. The therapists had a very active attitude in approaching the patients and using the new insights.
On Tuesday -as planned- we gave presentations for the plastic surgeons, residents and the hand therapists in the library of the hospital. Ilona started with a presentation about extensor tendons and the ICAM protocol. After that Ellen took over with a presentation about hand therapy after burns and the role of silicon applications and pressure garments in scar management.
In the following days we noticed that the presented information was applied clinically by plastic surgeons as well as therapists. At the request of Dr Nakarmi we did a short presentation on Thursday about CRPS and graded motor imagery. We felt that the visit to Kirtipur Hospital was very useful. We think that the challenge for the Kirtipur team is to incorporate all the information from different expatriate therapists into their own way of working.
link to the centre:
– Ellen de Boer & Ilona Zuiderman