Rehabilitation support to Storm Injured People in Bara

and Parsa Date of Response: 7th to 19th April 2019

Physiotherapists of Naryani Hospital Conducting the Post Hospital Rehabilitation in Community

Snapshot of the Rehabilitation Response

125 in the need received rehabilitation services. Out of 125, 71(57%

received rehabilitation services from community. More than 50% of those

receiving the rehabilitation in community were initially discharged from the

hospital without ensuring any rehabilitation services.

130 assistive devices were delivered (Crutches, Braces, Walker, Walking

stick and Wheelchair). 90 devices directly delivered to injured people and

40 handed over to the Naryani hospital for follow up cases.

86 follow up physiotherapy sessions have been conducted for severe cases

Completed the line listing of cases receiving rehabilitation and handed over

to Naryani Hospital physiotherapy department

68 people need physiotherapy for more than 3 months with atleast one

follow up in a week.

Rehabilitation service was delivered in government hospital, private

hospital and all the affected community

Rehabilitation service was delivered in coordination of local health

emergency operating centre, local physiotherapists and health coordinator

of municipality & rural municipality

1

Introduction

Two districts of southern Nepal, Bara and Parsa were hit by a deadly storm on the 31st March 2019. According to the statement from Health Emergency Operation Centre (HEOC) released on the 11th April, storm killed 28 people and injured more than 1110. The powerful storm destroyed local houses and trees causing injuries very similar to those caused by an earthquake. Of the two districts, Bara is the most affected where the largest health facility is only a government district hospital with no surgical and rehabilitation facilities. Storm affected all group of population from children to people with disability, pregnant mother and elderly people. The Birgunj city of Parsa district has a tertiary government hospital plus some private hospitals with provision of surgical as well as rehabilitation facilities. As a consequence, the most severely injured (both Parsa and Bara districts) were brought to Birgunj city for medical treatment. Nepal Physiotherapy Association (NEPTA) requested one of its members for an initial need assessment which showed that fracture and soft tissue injury as the most common injuries. These types of the injury needs rehabilitation service right from the first day in order to ensure wound healing, to prevent disabling complication and to enhance functional activities as early as possible.

Map of storm affected districts (Source: National Emergency Operation Center), Source WHO Nepal

2

Ministry of Health & Population (MoHP) and Leprosy Control & Disability Management

Section (LCDMS) of Epidemiology & Diseases Control Division (EDCD) identified the

unmet need for rehabilitation services for storm injured people in Bara and Parsa

Physiotherapist of Naryani hospital, Birgunj expressed the high need of physiotherapy in

storm affected district that was also recorded in a health emergency meeting minute

held in Naryani Hospital

MoHP assigned Humanity & Inclusion (HI), National Disabled Fund (NDF) and Nepal

Physiotherapy Association (NEPTA). Coalition (annex 1 &2) of these organizations has

delivered rehabilitation services both at hospital and storm affected communities.

Functioning of this coalition was guided by local Health Emergency Operation Centre

(HEOC) Birgunj, Central HEOC and EDCD that means rehabilitation service is being

delivered through one door system of MoHP and its local entities.

Services offered: Physiotherapy and Assistive devices (Mobility aids and braces): fitting

and user training.

Framing rehabilitation service delivery to the local need: Guided by need assessment

that was jointly done with multidisciplinary local health team on the 9th April 2019.

Coordination for the patient appointment was done through local health coordinator of

rural/municipality who is requested to show person in limb cast, implant or with soft

tissue injury to be benefited by rehabilitation services. In addition, door to door case

hunting was jointly done with health coordinator or person assigned by him/her on the

most affected areas

Areas covered: Hospital based rehabilitation on Naryani hospital, National medical

college, Birgunj health care, LS neuro hospital and Gandak hospital. Community visit to

identify and manage the injured people on Bara district- Pheta, Gadhimahai ,

Subarnapur, Parsauni, Parwanipur, Kalaiya municipality and Pachrauta and Devtal

In Naryani and private hospital rehabilitation was done in leadership of their own

physiotherapist while response team was providing the back up support and assistive

devices for the early ambulation/mobilization of patients.

3

Aligning to the local health system

Participated & reported on all meeting facilitated by health emergency management

centre

Provided Humanity & Inclusion vehicle and rehabilitation human resource for health

related need assessment (rehabilitation embedded) of affected community conducted

by local Health Emergency Operation Centre

Collaborated with the physiotherapist of existing hospitals to ensure rehabilitation in

his/her ownership

Conducted the joint rehabilitation and psychosocial (TPO) field visit in community using

HI vehicle

Worked in synergy with physiotherapists (Annex 3) of Naryani hospital for the handover

of rehabilitation service

4

Preparation adopted for the handover of rehabilitation services

o A request letter (Annex 4) was forwarded to medical superintendent of Naryani hospital

for mobilizing its 4 physiotherapists both in hospital and in community for the

rehabilitation of storm injured who were already discharged.

o Medical superintendent has written the formal instructive letter (Annex 5) to

physiotherapy department in charge of Naryani hospital to ensure the follow up

rehabilitation of injured living in community

o On the 17th of April, the health partner meeting of DPHO Bara has also decided to

request one physiotherapist to Provincial government and Epidemiology & Diseases

Control Division.

Handover to the physiotherapist of Naryani Hospital (18 & 19 of April)

Meeting with the team of Naryani hospital physiotherapist was facilitated to debrief

the need of rehabilitation of injured survivor discharged to community

All line listing of cases who received first level of rehabilitation was explained and

handed over (individual client assessment sheet, trauma summary sheet of

municipality/rural municipality and client database) to Naryani hospital physiotherapy

department

Jointly two community field visits were conducted with two physiotherapists of Naryani

hospital in order to orient the scenario in community and how to work in coordination

with health coordinators of rural /municipality

Essential assistive devices that might be required in coming days for the injured

survivors was also formally handed over to store of Naryani hospital (annex 6 and

annex 7)

It has been explained to Mr. Uday Mishra (Naryani hospital, physiotherapy team lead)

that any extra support need for rehabilitation in coming days should be immediately

formalized to medical superintendent then to concern provincial and MoHP entities

Based on the number of injured needing rehabilitation services, Naryani hospital

physiotherapy team plans a field visit to 3 clusters in Bara: Pheta, Subarana + Pachrauta

+Devtal, Parsauni+Parwanipur.

A team of two physiotherapists will have a community visit in a vehicle arranged by the

Naryani Hospital.

5

Rehabilitation service pathway for community jointly agreed with PT team of

Naryani hospital

Pertinent issues and recommendations

Disaster help desk is required in Naryani Hospital to guide follow up cases. Clear linkage

of this desk needs to be created with social service unit which has mandate to

coordinate the care for disaster injured

A clear consensus needs to be made regarding where the disaster injured case should

be sent for the follow up from the community. Especially for those who have received

the first level of intervention from private hospital.

Dressing should be arranged near to the location of most affected areas. All the injured

survivor might not be able to reach the health facility for follow up

The need of rehabilitation in terms of intervention time might increase after the

removal of cast and implants because it needs more time to mobilize the stiff joints. This

might call the back up support to physiotherapy team of Naryani hospital.

Bara district hospital is closer by the affected communities where injured people will go

for follow up. However, there is no physiotherapy department on this hospital at

present. It is also important to depute one physiotherapist in Bara hospital who should

work in close coordination with the physiotherapist of Naryani hospital (hub) and also

6

can provide the back up support to rehabilitation team of Naryani hospital. A partner

and government health staff meeting held in Kaliya hospital has identified this

need.(Annex 8)

The backup support needs of Naryani hospital physiotherapy team should be time and

again reviewed at the Naryani hospital, provincial and EDCD level.

A government focal person with rehabilitation profile needs to be deputed at provincial

level and MoHP/DoHs level for the surveillance of rehabilitation work going at storm

affected areas. The surveillance information should atleast cover; Rural/ Municipality,

Name of Patient, intervention delivered and any complications indicating to the long

term disability. This information should be compared to the already line listed data of

injured patients.

Most of the affected areas are inhabited by the Dalit and Muslim community. There

should be a mechanism to cross check the impartiality and localization on aid.

Psychosocial interventions specially targeting the injured people needs to be started.

There might be the need of one experienced person who can coordinate and depute the

existing psychosocial workers of different organizations through properly framed plan

Emergency trauma management training (NHTC endorsed training) which was already

done in province number 3,5 and 7 is must to ensure the multidisciplinary trauma care

at hospital level in mass causality. But this is not urgent as patients are already

discharged from hospital. However, this should be considered as preparedness initiative

of mass causality in province 2.

A short hands on training (3 days) to health workers (Health post and PHC) on basic

integrated rehabilitation follow up care of injured patients is required in order to ensure

the continuum of rehabilitation at the community level. This training should be

integrated that means covering all types of injury occurred due the storm. After 2-3

weeks, removal of limb cast will start after which need for rehabilitation will further

increased as it needs more dedicated time to mobilize joints and strengthen muscles.

Therefore, the right time to start this training is not later than 2 weeks from today (29-4-

2019).

15 people with disability who were not injured but affected by the storm were

consulted during the community visit. Most of them do not have assistive device and of

those who are using it are not in good condition. A rehabilitation camp with the

provision of assistive device is required in order to ensure personal mobility of these

people.

7

Acknowledgement

We would like to express our sincere gratitude to the following person whose contribution was

vital to form and guide this team

Name Hospital/Organization Support

Dr. Kedar Prasad Century Director, Bir Hospital Deputing Mr. Sujeet Singh in request of Nepal Physiotherapy Association

Dr. Pramod Kumar Yadav Chief Medical Superintendent, National Trauma Center

Deputing Mr. Pravin Kumar Yadav in request of Nepal Physiotherapy Association

Dr. Basudev Pandey Medical Superintendent, Sukraraj Tropical and Infectious Diseases Hospital

Deputing Mr. Nabin Jaiswal in request of Nepal Physiotherapy Association

Dr. Anamul Hauq Medical Superintendent, Naryani Hospital

Creating enabling environment to establish rehabilitation care and handover the post-hospital care to Naryani physiotherapy department

Mr. Yam Nath Mainali Secretary , National Disabled Fund

Deputing one Prothetist& orthotist and Wheelchair technician. Releasing the stockpiled assistive device. Commitment to provide prosthesis for two amputee

Mr. Willy Bergogne Country Director , Humanity & Inclusion

Deputing HI staff to HEOC , MoHP for each health cluster meeting and sending 4 HI staff for rehabilitation response. Releasing HI stock piled assistive devices for emergency. Approving the travel and accommodation cost of entire team members of rehabilitation coalition

Mr. Laxman Adhikari President, Nepal Physiotherapy Association

Mobilizing 3 physiotherapists experienced on trauma management through Bir hospital, National Trauma Center and Sukraraj Tropical and Infectious Diseases Hospital. Participating on

8

health cluster meeting at HEOC to convey the need of rehabilitation service.

Mr. Uday Mishra PT, Naryani Hospital For providing the real information on the surged need of rehabilitation services and collaboration

Mr. Om Prakash Sah PT, Naryani Hospital

Mr. Satya Naryan kumar PT, Naryani Hospital

Mr. Dhan sundar prasad yadav

PT, Naryani Hospital

Mr. Baiju Jaiswal PT, National Medical Collage

Mr. Mitlesh Yadav PT, National Medical Collage

Mrs. Reycha PT, LS Neuro Hospital

Miss. Nirpendra Karn PT, Ex-general secretary of Nepal Physiotherapy Association

Dr. Erana Joshi WHO Providing the contextual information and helping to connect with health coordinators and other local health actors

Dr. Soniya Bhagat WHO

9

Some Glimpse

Physiotherapist facilitating the

ambulation of an elderly in Kaliya

hospital

Size of crutches being adapted

to the height of injured person A physiotherapist supervising the

ambulation of injured

Women with injury learning to

walk with crutches at her

community

10

Annex 1: Letter from Ministry of Health and Population to the coalition of Humanity &

Inclusion, National Disabled Fund and Nepal Physiotherapy Association

11

Annex 2: Composition of Rehabilitation Team deputed by MoHP

Name Organization Profession

Sunil Pokhrel Humanity & Inclusion Physiotherapist(Team Lead)

Pravin Yadav National trauma centre, supported by Nepal Physiotherapy Association( deputed from 7th -12th April)

Physiotherapist

Nabin Kumar Jaiswal

Sukraraj Tropical and Infectious Diseases hospital, supported by Nepal Physiotherapy association

Physiotherapist

Sujit Singh Bir hospital, supported by Nepal Physiotherapy Association(deputed from 14th April to 19th April)

Physiotherapist

Rati Gurung Chautara district hospital, Sindupalchok (Humanity & Inclusion staff)

Physiotherapist

Ram Bdr Thapa National Disabled Fund, Social welfare council, Ministry of Women Children & Senior Citizen

Prothetist & Orthotist

Ramhari Lamsal National Disabled Fund, Social welfare council, Ministry of Women Children & Senior Citizen

WHO certified wheelchair service personal

Mohan Bhatta Humanity & Inclusion (( deputed from 7th -9th April)

Logistic coordinator

Krishna Duwal Humanity & Inclusion(( deputed from 7th -12th April)

Driver

Lal bahadur chaudhary

Humanity & Inclusion(( deputed from 12th – 19th April )

Drive

Team: 1 Female , 10 Male and 1 person with disability

Annex 3: Physiotherapy Team of Naryani Hospital

Name Email

Mr. Uday Mishra physiouday4u@gmail.com

Mr. Om Prakash Sah sahomprakash331@gmail.com

Mr. Satya Naryan Kumar modern_phy@yahoo.com

Mr. Dhan sundar Prasad Yadav

dhansundar2012@gmail.com

12

Annex 4: Emergency rehabilitation coalition requesting the medical superintendent of Naryani

hospital to mobilize the physiotherapist for rehabilitation of storm injured people

13

Annex 5: Instruction given by medical superintendent to head of physiotherapy department of

Narayani hospital to lead the rehabilitation in response to the request letter of rehabilitation

coalition

14

Annex 6: Assistive devices donated speculating the further needs during the community follow

up by the rehabilitation team- Humanity & Inclusion (5 pairs of auxiliary crutches, 2 Anti-

bedsore mattress and 4 walkers).

15

Annex 7: Assistive devices donated speculating the further needs during the community follow

up by rehabilitation team- National Disabled Fund (2 pairs of Axillary crutches, 2 wheelchairs, 5

knee immobilizers, 5 wrist splint, 10 arm slings and 5 ankle braces).

16

Annex 8: Minute of DPHO meeting in Kaliya Bara held on 17th April 2019 identified need for

having one physiotherapist at Kaliya district hospital

17

18

Forms & Format used and handed over to Naryani Hospital Physiotherapy Team

Emergency Rehabilitation Assessment Form

Name: Age: Gender: M/F

Address ( ward, municipality/rural municipality & District) :

Hospital/Health facility Name: Type: IPD/OPD/Outreach

Disability card Yes/No: Red/ Blue/ Yellow/ White/Not app Contact number of client:

Diagnosis: Left/Right/not app…………………………………………………………………………………………………………………

Treatment: conservative/surgery……………………………………………………………………………………………………………

Causes: Strom/specify others………………………………………………………………………………………………………………….

Assessment Findings:

Muscle power: ROM: Balance:

ADLs: Complications:

Others:

Rehabilitation Intervention Details

Session Specify the Rehabilitation Intervention Specify Assistive Device (If Delivered)

Signature of Rehabilitation Professional

1

2

3

4

Smart Goal Setting Goal: Goal set Date: Status: under review/Achieved/Not achieved

Referral: required/not required Place where referred :

Any comments(Future follow up needs, any risk for long term disability and constraints that can impact the prognosis ):

19

Follow up form

Rehabilitation of Bara Parsa Storm Victims:

Name of hospital/community health facility (village, ward):

Date:

Name of patients Age/Sex Diagnosis Treatment/ Surgery Rehabilitation sessions/ follow up

Date Date Date Date