Nepal, a landlocked country between India and China, is one of the most disaster-prone nations in the world. According to the European Union, the intensity and frequency of these disasters is growing because of its location and climate.

Nepal contains 80 per cent of the world’s highest mountains and has a population of almost 30 million, with 66 per cent living in urban environments.  

The country has recently made a commitment to universal healthcare (UHC) and responsibility has been devolved to a federalist model within an underpinning legal framework set by central government. However, this is set against a historical backdrop of multiple donor-driven vertical programmes over previous decades. 

 A GROWING CONCERN

The UK Foreign, Commonwealth and Development Office has highlighted that there is no central public ambulance service in Nepal. 

However, a Government of Nepal publication has declared that establishment of a national ambulance service is being developed as part of National Ambulance Guideline 2078. The report also states that trauma management facilities near highways and urban areas are being prioritised, and Gandaki Province has upgraded three centres to improve emergency medical services. The centres are equipped with an MBBS doctor, nurse and an ambulance with a health assistant and a GPS fitted. The World Health Organisation and EU delivered basic emergency medical technician training to strengthen pre-hospital care in 2021 and trained 50 personnel and some trainers.

There is a recognition at government level that delivery of pre-hospital care can and should be improved as part of UHC.

Unsurprisingly, trauma is a significant cause of death in Nepal. Government reports cite death rates of 96 per 100,000 population from road accidents and 38 per 100,000 from other incidents, with falls being the most common causes.  

SUPPORT AND GUIDANCE

It is against this backdrop that we delivered a Pre-Hospital Trauma Care (PHTC) provider course in Nepal in February this year. This initiative follows on from the pre-hospital care workshop held in Chennai, India, in October 2022 and the delivery of two inaugural PHTC courses at the Sri Ramachandra Institute of Higher Education and Research (SRIHER) in April 2023, and a PHTC instructor course delivered in October 2023.  

The provider courses in Chennai had identified 18 candidates as having ‘instructor potential’ (IP) and the aim was to build upon their enthusiasm and focus to generate an instructor faculty in India and Nepal. Twelve of the IP candidates were able to attend the instructor course at SRIHER, which included presentations and discussions on teaching and learning styles and required the candidates to deliver short presentations, teach a skills station and run a moulage.

The instructor course was run by Dr Rob Russell of the Faculty of Pre-Hospital Care (FPHC) and Professor TV Ramakrishnan of SRIHER, who provided feedback and guidance to the candidates. Candidates also critiqued their colleagues’ performance. All of the candidates were successful and went on to run a PHTC provider course in the subsequent two days, once again with oversight. A further 18 providers were trained on the latter course and a number of other IPs were identified, establishing firmer foundations for the future.

SUCCESS STORY

Professor Ramesh Maharjan from Nepal completed provider and instructor training and asked the FPHC to deliver a provider course at the Nepal Disaster and Emergency Medicine Centre in Kathmandu. The PHTC course was timed to follow on from the Nepal Disaster Medicine and Management International Conference so that members of the UK team could participate in both events and maximise efficiency and economy. 

The UK team comprised Dr Rob Russell, course director, Dr Fionna Moore, FPHC doctor co-vice chair, and Dr Christina Dale, immediate past president of the Faculty of Conflict and Catastrophe Medicine.  The faculty was completed by Professor Maharjan. Funding was generously provided by charity Saving Lives International, which we had previously worked with and which had hosted an event at the House of Lords in September 2024, attended by members of the FPHC Executive and His Excellency Gyan Chandra Acharya, the ambassador of Nepal to the UK.

The 21 candidates on the FPHC PHTC course were all doctors and covered specialties such as emergency medicine, orthopaedics and family practice. Seniority spanned residents to professors. The majority of the candidates came from the southern, more populated, part of the country and Kathmandu area. Ultimately, the hope is to project the course to more rural areas and provide quality pre-hospital care at the earliest point after injury to reduce mortality and morbidity during transfers to definitive care.

The India version of the PHTC course was edited to make it more specific to Nepal and all scenarios were rewritten to ensure that they had a more Nepalese flavour.  Candidates performed very well throughout the course and in the final moulages. Only one candidate was unsuccessful in the moulages. Feedback was universally positive with comments such as ‘excellent’, ‘exciting’ and ‘essential in the Nepal context’.

FUTURE PLANS

However, the candidates’ performance in the MCQ did not entirely reflect their practical competence and experience. This has been reviewed in detail by the course director, with input from the rest of the faculty and the candidates, and it was clear there were a number of reasons and these are being/have been addressed. Furthermore, the recent Nepal and India courses prompted a re-edit of all the PHTC presentations to make them more focused and this has been completed as part of ongoing quality improvement.

The course was a success and we have been asked to deliver more training and an instructor course to allow the training to be delivered by local instructors, with periodic FPHC quality assurance visits, to embed the training within the country’s developing pre-hospital care system.