My Journey in Orthopedics since 1997 in Nepal

As a young orthopedic surgeon, I returned to Nepal in May, 1997 after finishing six years of medical education and one year of Turkish language training and five year of hectic residency in Hacettepe University in Turkey. I imagined at that time my experience in Nepal would be challenging. What could I have thought at that time? May be to excel in my profession as a surgeon by treating many patients with disabilities, to make some descent income for a comfortable life and contribute to our society in the long run. The opportunities seemed not great at that time. Getting a job was not easy either. Coming from cutting edge technology to the most underdeveloped system was not so easy.

My first experience as a doctor to work in one private clinic called Apollo Hospital clinic in PutaliSadak seemed fruitless. I worked three days there. There was nothing. There was not even a plaster cutter or anything to be able to intervene patient. But I was told that a great Apollo Hospital will be ready soon in Balaju. Without seeing single patient in three days, and making income of zero rupees, seemed impossible to sustain my life in Kathmandu.

Then, with my degrees and experience, I knocked the door of Tribhuvan University Teaching Hospital, Department of Orthopedics. I met Prof. Dr. Lakhan Lal Shah and he was kind enough to show his department. He also took me in his ward round. We had a long discussion regarding diagnosis, treatment planning and physiotherapy. Many of their treatments were not the same the way that I was taught in Hacettepe University. But it was interesting and seemed I will be able to exercise my knowledge. Next thing came in my mind; how can we get modern technology? After our mutual and respectful discussion, Prof. Shah thought I may be a good candidate for them, and I am thankful that he gave me appointment letter. However, this appointment letter had to go through the series of bureaucracy for the final approval. It took weeks and sometimes very difficult to reach to the end. So, my planning to join TUTH could not be realized.

In the meantime, Dr. Victor Goldberg whom I had met during my residency in 1994 in Hacettepe University in Turkey turned out to be Dr. Ashok Kumar Banskota’s friend. He had told me if ever I go back to Nepal, he had asked me to say hello to Dr. Banskota. This is how I visited Dr. Banskota in his Kathmandu Nursing Home to convey his regards. After discussing with Dr. Banskota about orthopedics in general and practices in Nepal, I took few days for my decision whether to work with him. Dr. Ravi Thapaliya, my colleague form Amrit Science College kept on following me about my decisions starting to work with Dr. Banskota. So, in a few days’ time, I decided to work with Dr. Banskota in his nursing home. I was keen on trauma care, arthroscopy, joint replacement and pediatric hip problems mainly congenital hip dislocation. At that time, Ponseti club foot treatment was not popular, and we were trained to do surgical management for club foot. The volume of work in KNH and HRDC (Hospital and Rehabilitation Centre) matched my ambition to serve more people in Nepal. Twenty thousand monthly salary gave me footing in Nepal to pursue my ambition in orthopedics. After few months I continued my work in newly built BNB and HRDC Hospital in Gwarkho, Lalitpur and Banepa until June 2002. My goals were clear. I wanted to start training program in Orthopedics and change the paradigm of Nepalese orthopedic care. Research for now and for the future to make international standing of our country. I delivered first weekly class in BNB, “My Five Years Orthopedic Residency in Turkey”. These further paved the way for orthopedic residency with Kathmandu University. Contributions were very clear with Dr Banskota, Dr. Jwala Raj Pandey, myself and Dr. Babu Kaji Shrestha. Later on Dr. Ishwor Pradhan joined this team for the similar purpose.

After my departure from BNB hospital, I created orthopedics and trauma department in Medicare Hospital. I continued from 2002 July to 2012 December. I realized few important things at that time.
1- Managing infection control in orthopedics
2- Making proper operation theatres where patients safety is the highest priority
3- Team which can make medical diagnosis and proper referral
4- Proper lab or radiological imaging ordering decisions
5- Timely intervention for the problem
6- Continuous medical education and problem solving
7- Medical waste challenges including medical sewage management

I also realized by working with Dr. Rishi Kumar Kafle (Consultant Nephrologist) and Dr. BB Sharma (Consultant Psychiatrist) that patients come in different forms. For example, immune compromised due to renal transplant case, infection behaves very differently in Dr. Kafle’s cases. Diagnostic dilemma and antibiotics or antifungal treatment is completely different. A patient comes for thumb pain, and he wants me to amputate his thumb. On clinical examination, I find nothing medically. After referring this patient to Dr. Sharma and after his antipsychotic medication, patient’s pain disappears and he does not want his thumb amputation anymore. Another patient very active golf player brings his brother with multi-joint pain to my clinic. In between conversation, he asks question to me that he has left scapular or shoulder region pain, and he suddenly asks for my opinion about it. I looked at his face and he seemed very anxious. I was alarmed by looking at his face. I had of the feeling that he may be developing myocardial infarction (cardiac arrest). I immediately put him in the wheelchair and rushed to the cardiac department by myself. It proved that he was having inferior wall MI. After quick streptokinase thrombolytic injection and stenting at Gangalal hospital he survived. Interestingly, he is still playing Golf. Meeting him after 21 years recently was a great gift as a medical professional.

Case like night duty doctor missing to realize leg compartment syndrome of a footballer after tibia fracture nailing is alarming. I salvaged the leg by late compartment release. But he had to change his job from footballer to another one. I was fortunate to make him change his mind to be a doctor. Hundreds of such events persuaded me to make an institution where knowledge meets practices; heli rescues and treatment from ground Zero saves people’s lives. Where multiple departments under one roof with good medical leadership changes future of our country’s healthcare destiny. Well-read doctors, nurses, engineers, technicians, paramedics together can diagnose, intervene and save patients’ lives in golden hours (2 to 4 hours). This brings the birth of Grande International Hospital. Again, making hospital or institutions is challenging. However, sustaining and keeping institutions perpetually vibrant and excellent in clinical outcome is daunting.

I believe intellectuals need time to read, think and execute. They can only do this if there is a good environment to do so. A worthy treatment, useful research, humanely institution is only possible by altruistic team.

After this roller costar orthopedic journey, I am now finally at Anamiwa Health & Hospital serving patients by my own way but with 100 people working in a greater harmony. It is small but education has been at the core of this institution. Prevention with timely diagnosis, physiotherapy, lifestyle modifying techniques and loving nature has been our goal. If we ever must do any surgery, we do it in a greater precision whether this may be joint replacement, trauma care, sports medicine, pediatric care or any other interventions.

Finally, making institutions need hard work of generations and nourishment by individuals both from private and government sectors. A good healthcare member are the greatest asset of the civilized society and their care both psychologically and financially will ensure better well-being of our whole society. Producing leaders in any profession needs decades of investment, having excellent medical team will change destiny of our society. My work as a doctor will continue to make this society worthy of living.