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Emergency Neurological Life Support Courses in Nepal

By Currents Editor posted 09-18-2018 15:18

Photo_Gentle_S_Shrestha.jpgBy Gentle Sunder Shrestha, MD, FACC, EDIC, FCCP, Neurointensivist, Assistant Professor, Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal

Nepal is a landlocked South Asian nation, bordered by China on the north and India in the south, east and west. Nepal has the population of around 26.4 million, with the land area of 147,181 km2. The GDP of Nepal is USD 837 per capita. Countries like Nepal and other low- and middle-income countries (LMICs) have a high burden of neurological emergencies.

The burden of disease may be higher than in the Western nations, and the outcome is dismal. Several factors contribute to this scenario, including the difference in disease epidemiology, poor pre-hospital transport and care, healthcare infrastructure, poor awareness among public, scarcity of resources and limited trained healthcare workers. There is a chronic shortage of human resources for health in Nepal, with the density of seven per 10,000 populations. Moreover, as compared to other specialties, the trained people in the fields of neuroscience is very limited. Most of the neurological emergencies are dealt with by the healthcare workers with minimal expertise in the field of neurosciences. Training these first line healthcare workers is of paramount importance to enhance quality of care and thus to improve outcome for the patients with neurological emergencies. The first ENLS course was conducted on Feb. 21, 2015, at Tribhuvan University Teaching Hospital, Kathmandu, Nepal with Dr. Victoria McCredie as the course director. Dr. Alberto Goffi, Dr. Antonio Bellini and Dr. Gentle S Shrestha served as the trainers (Figure 1). The landmark course was also the first course conducted in Asia. The course was attended by the doctors from various specialties involved in managing neurological emergencies, like emergency medicine, critical care, anesthesiology, internal medicine, neurology and neurosurgery.

Knowledge and effectiveness of the course was assessed among the 34 participants, at baseline, post-course and six months following completion of course. The course was found to be effective to enhance knowledge, decision-making skills and clinical practice, which persisted at six months following the course. The findings of this prospective observational cohort study was published in an international journal. Following the landmark course, there was increased interest among the local experts to become the ENLS trainers. At present, we have eight certified ENLS trainers in Nepal. The landmark course was followed by three other courses in Nepal. All the courses were very well attended and were focused to train the first line healthcare contact with good involvement of medical officers and nurses.

ENLS was well perceived by the national medical societies. One of the courses were conducted on May 2017 as the pre-conference workshop during the international conference of Society of Internal Medicine of Nepal (SIMON), the largest medical society of Nepal (Figure 2). We had the gracious presence of Professor J. Claude Hemphill III during the very course. The need of the course was perceived outside the capital city Kathmandu, as well. We conducted a course at Biratnagar, a metropolitan city, located 400km east of Kathmandu, on April 2016 (Figure 3). The course was hosted by Birat Medical College and Teaching Hospital. In another course conducted at Kathmandu in December 2015, which was attended by over 75 participants, we conducted a questionnaire survey, just before starting the course, to explore the knowledge about acute ischemic stroke among the participants. The overall knowledge about the risk factors, diagnosis and management of acute ischemic stroke was poor, thus highlighting the need of training programs and courses like ENLS.

Fig_1.jpg(Image above: First ENLS course in Asia, conducted on Feb. 21, 2015, at Tribhuvan University Teaching Hospital, Kathmandu, Nepal.)

 All the courses were conducted with a nonprofit motive. The dedicated core group of trainers intend to continue to conduct ENLS courses at Kathmandu and outside the capital at regular intervals with the aim to improve knowledge, and thus the quality of care during neurological emergencies. Two of the ENLS trainers from Nepal, Dr. Subhash P. Acharya and Dr. Gopal Sedain, have volunteered to help conduct ENLS courses in Sri Lanka. I have been involved in 12 courses, as course director and/or trainer, in Nepal, Sri Lanka, India, United Arab Emirates and United States. The generous support from NCS and the officials for the courses have been very much appreciable. Based on the feedback from the participants and the trainers of the courses conducted in Nepal, Sri Lanka and India, we perceived the need to develop modules for dealing with neurological emergencies in places with significant resource limitations, where some basic interventions, even in the absence of advanced diagnostics and trained experts, can still save lives and improve outcome in patients with neurological emergencies.
(Image above: ENLS course conducted on May 4, 2017, at Kathmandu, as a pre-conference workshop of international conference of Society of Internal Medicine of Nepal (SIMON). Professor J. Claude Hemphill III served as the NCS leadership and a trainer.)

(Image above: ENLS course conducted on April 23, 2016, at Birat Medical College and Teaching Hospital, Biratnagar (a metropolitan city at eastern Nepal).)

(Image above: ENLS course conducted on June 5, 2017, at Colombo, as the post-conference workshop during CritiCon Colombo 2017, organized by Sri Lankan Society of Critical Care and Emergency Medicine together with Sri Lankan Society of Critical Care Nurses. Dr. Gentle S. Shrestha, Dr. Subhash P. Acharya, Dr. Gopal Sedain, Dr. Indranil Ghosh and Dr. Puvanendiran Shanmugam served as trainers.)

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