Nepal: Day Five

Source: Blog Post

It’s hard to believe it’s our last day here in Nepal.  The time simply flew by as we were having fun performing reconstructive hand surgery and learning together with our Nepalese colleagues.  But today was the best yet.  We began our day as we usually did.  The on-call residents gave morning report detailing the new admissions, inpatient census and cases performed over the previous day.  This report was followed by lectures given by Dr. Lalonde, where he discussed clinical pearls of hand surgery.  This rich discussion shared lessons with the group that Dr. Lalonde has learned from his experience in hand surgery.  These lessons are invaluable as they are not found in the medical textbooks; rather, these are gathered by real-world experience.  The talk was greatly valued by all who attended. 

It was at the end of the lecture that Dr. Shankar Rai, mentioned to the group that the OR nurses had been very interested in the concept of WALANT surgery.  In fact, the nurses had the brilliant suggestion that perhaps one of the unused rooms adjacent to the OR could be converted into a WALANT hand surgery room.  We had not thought about using the room they had mentioned.  It was right next to the OR front doors, but had a bunch of old anesthesia machines and operating room tables inside.  The suggestion sounded like a good one to us, but we had no idea how long it would take to get the room ready for hand surgery.  But then.   “We’ll do it today!”, Dr. Rai confidently asserted to the group.  We were quite excited by the team’s enthusiasm and even more excited by the thought of performing surgery in a true WALANT room! 

OR nurses began clearing out this unused room, which housed mostly old and unused items. 

We made our way upstairs to the OR and took a look at the room.  The nurses had already begun to clear the items and to our astonishment, it was perfect.  Jan Lalonde assisted the nurses in setting up the room to be efficient, modeled after the WALANT rooms that Dr. Lalonde uses in his practice.  Within an hour, the room was ready for WALANT hand surgery.  The visiting educator team was very excited for the Kirtipur hand surgery team, but not as excited as the Nepalese Hand Surgeons themselves! 

Dr. Lalonde, Dr. Shrestha, Dr. Narkarmi, Dr. Chaurasia are excited with their new WALANT room, which will allow them to provide affordable hand surgery to the people of Nepal!  We will send them an official WALANT sign when we get home. 

Now that we had a room we proceeded to perform three complex hand surgery reconstructions.  The first person we treated was Surrendra, a 25-year-old young man who suffered a burn to the dorsum of his dominant left hand.  His wounds slowly contracted as they healed, which severely deformed his small finger and ring finger in extreme extension.  Dr. Shrestha began by independently administering local anesthetic using Dr. Lalonde’s painless injection technique.  Sure enough, Surrendra only felt the small discomfort of the first needle poke.  We then proceeded to perform a successful cases of scar contracture release using WALANT technique.  Surrendra was comfortably the entire time. 

Ready for WALANT surgery in our WALANT room.  The room is perfect!  Thank you, Jan and the nurse team for the idea and setup!

Preoperative planning and administration of local anesthesia. 

We then met with our second patient named Irshard.  He is a 20-year-old young man who suffered a laceration to his forearm about 1 year ago in an industrial accident.  He injured tendons and his ulnar nerve, which were all repaired at the time of injury in Nepal.  However, his ulnar nerve has been very slow to regain function, which resulted in the wasting of his intrinsic hand muscles.  Irshard has been unable to work manufacturing aluminum window frames secondary to his hand weakness.  We proposed that we would perform a nerve transfer surgery which takes his anterior interosseous nerve and transfers it to the motor branch of his ulnar nerve.  The team took on the challenge of this complex repair.  They performed a beautiful and precise dissection during surgery, correctly identifying both nerves and seamlessly suturing them together.  Irshard understands that this repair will take months to see the benefit, but was so thankful to have been given the opportunity for the best outcome possible following such a devastating injury. 

Dr. Lalonde along with Dr. Shrestha, Dr. Chaurasia and Dr. Narkarmi performing a nerve transfer operation. 

We then met Adar, a 32-year-old gentleman who suffered a crush injury to his left hand in an industrial accident.  The Kirtipur team appropriately performed a reverse radial artery forearm flap along with k-wire fixation at the time of injury.  This procedure left Adar with a large skin flap over the dorsum of his ring, long and index fingers, attaching them to eachother.  Our plan was to begin releasing the digits and debulking the large flap.  Dr. Narkarmi performed the injection of local anesthetic in a painless fashion.  Dr. Lalonde was very happy and proud that the Nepalese surgeons demonstrated that they could independently perform the skills he had introduced to them.  We then proceeded to the WALANT room.  There, Adar underwent a flap debulking and syndactyly release.  He was so happy to his that he could independently move his fingers freely.  The immediate gratification that only WALANT surgery can produce was priceless. 

Dr. Lalonde, Dr. Shrestha and Dr. Chaurasia performing hand surgery in Kirtipur’s very own WALANT room. 

This last case marked the end of our trip.  The mission has been a complete success.  We have introduced novel techniques in hand surgery to our friends and colleagues in Nepal and they have eagerly demonstrated that they can successfully perform them.  The techniques of WALANT and field-sterility in particular can now be used in Nepal.  These techniques will allow our colleagues to provide AFFORDABLE and SUSTAINABLE hand surgery in this beautiful, developing country.  It is initiative such as these provided by the ASSH and ReSurge International that will continue to improve hand surgery capacity in low- and middle-income countries. 

The passion, sacrifice, talent and beautiful personality of each and every surgeon we have encountered here in Nepal has warmed our hearts, truly.  We have only spent five days with these wonderful people, but they have become part of our family.  It is amazing how despite all the barriers (language, culture, geography, etc), we have been able to come together and function as one unit through the language of hand surgery.  We are grateful for having been a part of this mission trip and can’t wait to return to Nepal in the future. 

Kirtipur Hospital at the end of our day.

Boudhananth Stupa.  Kathmandu, Nepal.