Dhaka Medical Centre College Hospital, Dhaka, Bangladesh
Bangladesh has a population of 160 million people and is one of the most densely populated countries on earth. The country is relatively young, having split from Pakistan during a war of independence in the 1971. GDP per capita is very low (nominal GDP per capita is a little over US$1300 per year). There are established, close links with neighbouring and regional countries for health service provision. There are 69 trained plastic surgeons in the country, of which 55 are still working. The enforced pensionable age in Bangladesh from public service is 59 . The vast majority of plastic surgery cases are burns. Electrical burns are very common, due to accidents with the electricity supply, along with scald and flame injuries.
Patient care is provided in the Government Hospitals, such as Dhaka Medical Centre College Hospital (DMCH), and in private hospitals, of which some have a charitable arm. Public hospital care is in theory free at the point of care. Due to poverty and a lack of prior investment in the public hospital system, public hospitals are in a constant state of overcrowding and frequently have an inability to provide all but the most basic care. There is a lack of beds, equipment, doctors, nurses and medicines. This results in a system whereby patients and relatives supplement the care provided by paying for equipment and some medicines, and also pay for care provided by dressers who supplement the very small number of qualified nurses available.
Current and past plastic surgery education in Bangladesh
There are two previous accreditation programmes for plastic surgery post graduate education, of which one is still running and ones has been been stopped (Fellowship and Masters) and a third: MS Residency programme, is in place instead of Masters. Fellowships for plastic surgery consisted of at least 2 years general surgery and 3-5 years plastic surgery; the Masters programme had an entry exam and 6 months in basic subjects, 2 years of General Surgery and 2 years of plastic surgery, both pathways were competed with an exit exam.
The current educational programme consists of 2 years in basic surgical/core training (and includes: 6 mo general surgery, 6 weeks radiology, 3 months medicine, 6 weeks ENT etc) and 3 years specialisation in plastic surgery.
There is an annual lecture series on plastic surgery, provided by local lecturers (attached) including all the subspecialties and the unit hosts the country’s only microsurgical laboratory, set up with the help of Ian Taylor, plus Interplast Australia and New Zealand.
Future expansion in plastic surgery and job prospects for local doctors.
Whilst most surgical specialities have 4 residents/year, (orthopaedics have 6), plastic surgery has 16 residents a year, and have already been asking for more to cover the need for reconstructive surgery.
In Bangladesh however there are not enough hospitals, and therefore not enough jobs for the number of doctors needed. For instance there are 700 orthopaedic surgeons, but they cannot get jobs, and have therefore started performing appendicectomies, circumcisions etc because in the private hospitals it is cheaper to have an operation performed by a non-specialist doctor (i.e. performing an appendicectomy for instance)
Present staffing levels, working week and resources at the Dhaka Medical College, plastic surgery unit
Dr. Sen is the founder director of Burn Unit and now the national chief coordinator.
The head of the department is Professor Kalam.
The immediate past head of department is Professor Shafquat Khundkar.
There are 2 further Professors Khondoker and Awwal, 3 Associate Professors Khan, Lenin and Anam, 5 Assistant Professors Tahmina, Tanveer, Uddin, Khan and Asfia and 14 residents, divided in 3 teams (red, blue and green), which each have 2 operating days in a 6 day working week (Friday off), and take care of approximately 150 patients each.
The unit officially has 100 beds. During winter months the hospital is at its busiest due to scald injuries and inpatient numbers are typically 500 patients or more, out of a total hospital population of 5000. The hospital typically stops admitting non-urgent plastic surgery cases in winter in order to deal with the burns workload. Only burns of 20% or greater are admitted generally.
There are female, male and paediatric departments including an ICU, HDU and two Hyperbaric Oxygen chambers. However, there are not enough trained nurses to be able to provide HDU level care, and no opportunity to ventilate patients long-term.
Planned plastic surgical institute at Dhaka Medical College
A 10 story building dedicated to burn and plastic surgery is planned at a site very near to the existing Dhaka Medical College. Building work is to start imminently and it i anticipated to finish in 2018.
BFIRST visit 30.11-15.12
Andy Williams and Claudia Malic, both Burns Consultants, visited in the week 30.11-5.12, our visit was hugely facilitated by Asst Prof Tanveer Ahmed. Professor Kalam and he providing us with official letters to use at immigration and arranging temporary medical registration, apart from daily transport to and from the hospital, including ensuring social activities after work.
We spoke on a number of subjects in Burns and Hand surgery as agreed with Asst Prof Tanveer Ahmed at the daily morning meetings for residents and senior staff. We also participated in the following operations, with the local surgeons:
Claudia: Claudia: CLP: Wide cleft lip right side, using Fisher type repair
Andy – Release of severe post-burns neck contracture and large full thickness skin graft; multiple z-plasties to axillary contracture.
Andy and Barbara – release of severe post-burns hand contracture and pedicled groin flap.
Barbara – lower leg and foot fasciotomies, skin grafting minor burns, amputation lower legs post electrical burn
Barbara Jemec, Consultant Hand Surgeon, visited 3-8 and 13-15/12 and spoke on Rehabilitation after flexor, extensor and nerve injuries, tendon transfer for low median and ulnar nerve injuries, fasciotomies and electrical burns (upper and lower limbs).
Feedback was overwhelmingly positive (breakdown attached).
The team had the opportunity to meet with Professor Shaquat Khundar, from the Popular Plastic surgery Centre and Popular Medical College Hospital, previously at the DMCH, but now retired. He founded the post graduate plastic surgery courses and was the trainer of most of the current senior plastic surgeons of the country and runs several charity programs.
Barbara furthermore had the opportunity to meet with two previous BFIRST Fellows and their discussion about the merits of the BFIRST Fellowship programme and training in Bangladesh (feedback attached), to attend a free clinic with Assistant Professor Tanveer Ahmed at the MH Samorita Hospital and Medical College and meet the CEO Mr. Mokbul Hossain.
Other NGO stakeholders
Current and past visitors to Bangladesh include Brian Sommerlad, Ron Hiles, Interplast Australia, Interburns, Smile Train, Operation Smile and ReSurge (Interplast US). Visits have been service-focussed (ie operating on clefts or burns), teaching focused or both. There has been little coordination between the various missions previously.
Challenges in plastic surgery in Bangladesh, with suggested improvements
Bangladesh has a huge population with a consequent large need for advanced plastic surgery services. There are, for example, 30,000 people in the country awaiting cleft lip and palate surgery. Whilst service type trips may provide a short-term solution, in a population this size, the only way to make sustainable improvements is to support the development of plastic surgery within the country. A number of key areas need to be addressed:
- Define the size of the problem. Record-keeping is poor to non-existent and trying to access prior medical records is also very hard. Defining the need is the first step in planning services to address the problem. It also allows arguments to be made at a government level about the need for funding, and allows improvements in care to be demonstrated. This also severely hampers any output in terms of research and audit.
Suggestion– the current generation of trainees in plastic surgery should be tasked with creating and maintaining a database of plastic surgery admissions. A minimum dataset might include patient demographics, details of injury or condition (eg a burns database might include mode of injury, percent burned, percent grafted), morbidity and mortality, and length of stay. Support should be given to these trainees to present this data nationally or internationally- for example, the British Burn Association (BBA) provides a scholarship for a doctor from a developing country to attend the annual BBA conference. The prevalence of laptops and smartphones within the trainee population is very high, so this is a low-cost, although relatively labour-intensive, improvement.
- Prevention strategies. A huge number of burn and hand injuries presenting to DMC are preventable. Support needs to be given to a programme to educate the population about the dangers of electrical wires, plus how to avoid scald and flame injuries, and suitable first aid. This is by far the most cost-effective improvement to outcomes available and needs to be a priority for those working within the country and those providing external support.
Suggestion– approaches should be made at a governmental level to support the use of a prevention programme.
- Plan for future plastic surgery needs. There are already plans within Bangladesh to build a national burn and plastic surgery centre, but also, more importantly, to outsource plastic surgery services to other cities and towns. This model depends on the training of a new generation of plastic surgeons plus an improvement in nursing numbers, funding for services, equipment, therapists, medicine availability and physical bed numbers. Support needs to be given to this model.
- Support for training of doctors, nurses and therapists via education programmes within Bangladesh, and opportunities for scholarships outside Bangladesh
- Encourage cooperation with the plastic surgery department in Jinnah Hospital , Lahore (who have just built a brand-new plastic surgery building in similar conditions to Dhaka)
- Provide help to senior hospital staff in Dhaka for an approach to government in order to plan future services. Health provision in Bangladesh is managed in a very hierarchical fashion; it is only with the support of the government that plans for a new hospital or for increases in staffing, equipment and services can be achieved.
Ongoing continuing care. The above improvements will likely take many years to implement fully and during this time there will undoubtedly be a huge continuing workload for plastic surgery services within the country. This workload can be supported externally, but not, as stated above, completely or indefinitely.
Suggestion– attempts should be made to coordinate service, teaching and aid activities between all the major stakeholders listed above.
We hope to have highlighted the following techniques:
foot fasciotomies, complete lower leg fasciotomies, release of severely contracted fingers, the use of adrenaline for donor site infiltration in burns patients, the position of safety for the hand and the importance of hand exercises.
In order to improve the outcome of donor sites we are advertising through the next BAPRAS bulletin for battery powered dermatomes (the discussion suitable dermatomes (electric vs air etc) has been had with the local doctors), and are contacting the sales manager at humeca Alsion Willox, BSc, DopHE Nursing (firstname.lastname@example.org).
Templates for compression garments, cloth samples for Jobbs, exercise protocols for tendon and nerve injuries, splint templates/examples and patient information posters are under development and will be forwarded to the DMCH asap.
We also suggest the introduction of Patient Champions, i.e. previous patients who visit the current patients, to tell them of their experiences, in order to facilitate the understanding of the doctors’ advice on treatment.