My Path to Nepal
By Lisa Gramlich, MD
I went on my first medical mission trip nearly 20 years ago. Since that time I have been on 19 trips. The desire to travel coupled with the curiosity to see other health care systems and experience other cultures on a very intimate level was my initial impetus. My desire to give back what I have been given and do so on a very personal level became my compulsion.
Being flexible and innovative are essential components of delivering health care in the “third world.” Some choose “developing countries” as a more politically correct term. I will not debate these terms, rather use them both to look at areas where one clearly seems to step 20-30 years back in time and other areas where progress is being made.
The preparation for my first trips consisted of me saying “Sure, I’ll go,” booking a flight and showing up at the airport. I then became the lead anesthesiologist on multiple trips, and was in charge of gathering equipment and a team for the pre- and postoperative periods, as well as intraoperative anesthesia. As many who are reading this article already know, that is a sizable amount of work!
In 2011, I co-founded Painfree Foundation (PFF) a 501(c) 3 company. As medical director of PFF, it was now my responsibility to make contact with the hosting hospital and physicians, hand pick all personnel from therapists to surgeons, appropriate all necessary equipment and medications, arrange transportation and lodging, ensure appropriate patients are coming for screening, and anything else you might think you’ll need. This task, I assure you, is daunting. Couple this with hosting a fundraiser or two, and one surely asks oneself “Why am I doing this?” For months, our basement becomes a staging area suitable for no other activities. My dogs sniff each new box as if they were interning for airport security!
I cannot in good conscience write an article on my experiences with global health without a discussion of a few of the ethical dilemmas I have encountered. They have helped mold the person I am and how I conduct myself with others when working overseas.
On my second trip, the surgeon who I had interned with under during my two years of surgery residency, asked if I wanted to do a cleft palate. I was thrilled he would have this faith in me and was eager for the experience. As one can imagine it took me a significantly longer period to do my first and only palate surgery than it would have him, an attending plastic surgeon with 30 years of experience. When I was done I was mentally exhausted and enamored with my work. I returned to my duties of supervising cases and working on the schedule for the following day. The number of remaining cases was staggering and the following day was our last. Families with children who had both cleft lip and palates and may have been offered repair of both were being made to choose one or the other. I began reflecting over the hour of time I had wasted doing the cleft palate and how much fun that had been for me. That fun seemed so misplaced now.
I had forgotten our primary purpose and in some ways my own Hippocratic Oath. Years later when I wrote a lecture for the medical students on the ethics of global health, I encountered many more written examples of these experiences. Now I ensure that I have the discussion about ethics with groups I lead. We are exposed to a variety of diseases, health and work conditions, and hardships we are not exposed to in the states, but we do not do overseas what we would not allow someone to do in the states.
The turning point to starting our own foundation came over a decade later on an orthopedic trip to Central America. I was to be the lead anesthesiologist for a group of surgeons I had not met, but who I was introduced to through colleagues. I asked to be put in contact with the anesthesiologist who had gone on several previous trips with them so I could try to get a lay of the land in the operating rooms there. I inquired whether he went through the DEA and brought narcotics with him or whether they were readily available there. He said no, he certainly didn’t bring any with him and narcotics were “spotty” in their availability there. I stated then that they must do the majority under regional and he said they did do some spinals, but there were no pumps to run epidural infusions nor was an ultrasound available. I was informed that “these people are very stoic.” This certainly was not the first time I had heard this of people in the third world. The very nature of the world they live in conditions them not to complain. My experience is they are extremely grateful even if you do have to stick them four times for an IV or they wake up nauseated.
Practicing yoga, I have beliefs that focused breathing (pranayama) and meditation (dhyana) are important factors in handling stress. This type of work is utilized by psychologists in pain clinics to help ameliorate chronic pain. The definition of stoicism is the endurance of pain or hardship without a display of feelings and without complaint. Synonyms include forbearance, resignation, fortitude, endurance, and tolerance. Used in a sentence, "She accepted her sufferings with remarkable stoicism." The majority of us cannot walk on hot coals without suffering. The lack of complaining does not insinuate lack of suffering, but I have heard that repeatedly reported about those we claim to medically minister to overseas.
Painfree Foundation was formulated on the principles of alleviating suffering in the perioperative period. Being able to link with a variety of surgical specialties means bringing this commitment of anesthetic perioperative care to various areas and assessing the needs of that particular area. When we began exploring the needs of various areas, burn care kept coming up. I am privileged to work in an institution with an excellent accredited burn unit.
Of the 5,795 total registered hospitals in the U.S., there were only 123 burn centers in 2011, down from 180 burn centers in 1976. Of these burn centers, only half are verified by the American College of Surgeons (ACS) and the American Burn Association verification criteria. Only 37 burn centers in the U.S. are verified to care for both adult and pediatric burn patients. For a facility to be recognized as a verified burn center, it must demonstrate competence in all aspects of patient care, from the pre-hospital setting through post-discharge rehabilitation. Centers also must have dedicated burn staff, treat a minimum number of patients per year, and maintain involvement in burn-related research.
More than 80 percent of the U.S. population lives within two hours of ground transport of a verified burn center. Most burn patients can be safely transported via ground to a specialized burn center for their care. For those patients who may to be too unstable to travel long distances, referring facilities can work with the burn center to stabilize the patient and prepare them for a safe transfer. To help health providers in non-burn facilities appropriately refer patients who are most likely to benefit from the multidisciplinary care offered at specialized burn centers, the ACS Committee on Trauma and the American Burn Association jointly developed burn injury referral criteria. Despite these criteria, only 40 percent of all burn injuries are treated in a burn center.
In Nepal, no hospital would qualify as an accredited burn hospital and only one hospital which just opened several years ago, has a separate burn unit. Since 80% of Nepal’s population lives in remote rural regions, transportation to this burn center is fraught with much difficulty. It was difficult for me to imagine the breadth of this problem until I went to Nepal. Much of the country is mountainous and without drivable roads, even in good weather. When the snows and the rains come, many areas become even more isolated. Very few Nepali own a motor vehicle and public transportation is scarce. If one asks a Nepali how far away their village is, they will have an answer very similar to “a two day bus ride and five day walk”. We treated a girl in Nepal with a 35% BSA burn who was placed in a large basket on a man’s back and hiked for 4-5 hours out of her village and then took a 16 hour ride on a public bus just to get to us. This type of lack of access to healthcare is difficult for us to appreciate.
Dr. Shankar Rai is a plastic surgeon who works tirelessly to bring reconstructive surgery to the people, namely the poor of Nepal. He embodies the altruistic spirit. Physicians in private hospitals make considerably more than those in public hospitals. With a significant part of his training being in the U.S., he could readily have a position in the private sector. Instead he and an entrepreneur, who is a carpet salesman, helped raise nearly a half million dollars, became an unlikely pair and teamed up to build Nepal Cleft and Burn Center on the outskirts of Kathmandu. Dr Rai realizes the importance of a dedicated burn hospital. Centralization and specialization of care has been shown in the U.S. to decrease mortality and morbidity. Prevention of disfiguring and immobilizing contractures will require early grafting and an active physiotherapy department. Improvement in morbidity will require anesthesia and intensive care education and capabilities.
According to a report from the Government of Nepal, 56,000 people suffer burn injuries each year and 2,400 die from these injuries. A 35% BSA burn in Nepal carries a 98% mortality, in contrast to a 30-40% BSA burn here in the U.S. which carries a 16% mortality. Functional outcomes from those who are burned are likewise staggering. On average, people wait 18 years from the time of acute injury to the time of reconstructive surgery in Nepal. This delay, along with increased mortality, leads to disfigurement and loss of functionality to various parts of the body. It was from sitting down with these statistics and Dr. Shankar Rai that we established what we believe is a realistic goal of <50% mortality for a 30-40% BSA burn.
According to the WHO, 11 million people sustain burn injuries every year and 95% of these come from low and middle income countries. Every year 320,000 people die from fire alone in Southeast Asia, the Global Epicenter of Burns. Like in the U.S., most of these are residential fires. In contrast to the United States, most of those afflicted are women, who are using open flames to cook. Another staggering number have intentionally been set on fire by themselves or others. It is difficult to verify the actual numbers.
There is a looming shortage of burn surgeons in the U.S. In a 2004 burn survey, Faucher and colleagues showed that the majority of burn centers needed, or will need, a burn surgeon in the next five years. Of the 152 burn surgeons trained in the preceding 10 years, only 40 percent of those were currently practicing at the time of the survey, demonstrating a noticeable attrition of recent burn surgeon trainees. A follow-up survey, published in 2011, showed improvement in attrition rates, but also a marked decrease in the total number of new burn surgeon trainees over the past 10 years (152 in 2004 versus 21 new surgeons in 2011, as reported by surveyed burn centers).
In 1984, Nepal had 80 surgeons and only six anesthetists - not even enough for the central hospitals of Kathmandu. It was at this time that the University of Calgary, Canada, Tribhuvan University in Kathmandu and the Ministry of Health in Nepal resolved to address the problem of anesthesia manpower by providing an in-country, one-year training program (leading to a Diploma of Anesthesia (DA). The University of Calgary offered to coordinate academic and administrative help for the first three years.
In 1985, the DA program was launched. Four or five candidates were accepted for training every year, and improved the manpower situation, as anesthetists became available to provide services in 10 hospitals outside the Kathmandu valley. By the 1990s, 44 DA graduates had been produced, although more than half left Nepal for higher training and better job opportunities.
In 1986, senior Canadian anesthesia faculty helped to organize the first Nepalese anesthesia symposium and formed the Society of Anesthesiologists of Nepal (SAN) in 1987. In 1988, SAN was accepted as a member of WFSA and in 1992, two Nepali anesthetists participated in a World Congress for the first time.
Owing to the difficulty of obtaining higher training outside the country and to avoid the loss of trained manpower, Canadian faculty members have helped to develop the training requirements and a three-year degree program was started in 1996. The first batch of MD Anesthesia candidates graduated in April 1999.
With many more government hospitals and private medical colleges and hospitals being established in the country, the limited number of trainee posts is unable to cope with the need for trained anesthetists. Nevertheless, the available trained and qualified manpower has provided great improvements in the quality of service and patient care, evidenced by the reduction in morbidity and mortality. In most hospitals, the anesthetic drugs and equipment are still limited and simple, but the practice of anesthesia has become much safer.
On our first trip to Nepal our focus was both on acute care and reconstructive surgeries. Though we were able to interact extensively with our surgical colleagues, an anesthesiologist only showed up for an hour one day we were there. We have since reengaged this anesthesiologist. Our hope with our return visit at the end of this year is to have a Nepali anesthesia provider with us every day. Along with acute burns, the focus will be ICU care of the burn patient. Establishing a strong relationship with some of the anesthesia providers in Kathmandu is quintessential in the educational process. I have also become highly motivated by the Society for Pediatric Anesthesia experience in Nairobi to develop a curriculum for pediatric anesthesia training in Nepal.
As I stated at the beginning of this article, I have traveled to many different places to work. Now I look forward to seeing the results of my commitment to one place. The Burn and Cleft Center in Kathmandu under the guidance of a remarkable Nepali surgeon, Dr. Shankar Rai, has the hope of changing the lives of many afflicted with burn injuries there. To be a small part of that process is a remarkable experience.