Member Spotlight: Raju Dhakal
January 14th, 2019
Dr. Raju Dhakal graduated Kathmandu Medical College and Teaching Hospital in 2007, earning a MBBS degree. After medical school, he served as a house officer and tutor at the Medical College and Teaching Hospital. In 2009, he began work as a physician at the Spinal Injury Rehabilitation Centre (SIRC) in Kaavre, Nepal, while also finding time to gain additional spinal rehabilitation experience through a clinical observership at the spinal injury program at National Rehabilitation Hospital in Dublin, Ireland. In 2012, he began his formal residency training at Bangabandhu Sheikh Mujib Medical University (BSMMU) in Bangladesh, with the support of the Vancouver-based SpiNepal group. His residency included 2 years of rotations in medical, surgical and pediatric specialities and 3 years of physical medicine and rehabilitation (PM&R). He did take some time off during his residency training to return to SIRC to volunteer following the devastating 2015 Nepali earthquakes, and to receive training at the Royal Melbourne Hospital (Melbourne, Australia), earning a title of Clinical Honorary Fellow. During his residency, he also had the opportunity to receive clinical training at the GF Strong Rehabilitation Centre (University of British Columbia; Vancouver, Canada) and the Toronto Rehabilitation Institute's Lyndhurst Centre (University of Toronto; Toronto, Canada). He completed his residency training at BSMMU in March 2017, then received further training at the Swiss Paraplegic Centre (Nottwil, Switzerland), before starting his current position on 29 May, 2017, as medical director and physiatry consultant physician at SIRC.
Dr. Dhakal is a member of ISCoS and the Asian Spinal Cord Network (ASCoN), the regional ISCoS affiliate. He has been highly active in the educational missions of these organizations, including presenting at conferences, chairing sessions, and participating in the initial editorial group that prepared E-learn SCI under the direction of Professor Harvinder Chhabra. He is also a member of International Society of Physical and Rehabilitation Medicine (ISPRM), where he serves as a member of the Rehabilitation Disaster Relief committee. He also serves as the Low and Middle Income Countries Representative on the advisory board for Cochrane Rehabilitation. Finally, he is a founder and president of the Nepalese Association of Physical Medicine and Rehabilitation.
Dr. Dhakal has received many awards during his education and career, including an ASCoN Fellowship Award, the Melbourne Health Award (from Melbourne University, Australia), an International Award for International Physiatrists (from the Canadian Physiatrists Research and Development Foundation) and a Kenes International and ISPRM travel grant award.
How did you become interested in becoming a physician?
Due to a lack of medical doctors, hospitals and vaccinations program in my village, I contracted polio at the age of two and developed paraplegia. Rehabilitation was not available at that time. I used to think: how could I develop medical care and rehabilitation for the people to have a dignified life despite impairment and disability? This is how I became interested in becoming a physician.
How did you become interested in becoming a specialist in rehabilitation medicine?
During my rotations in medical school, I found something was missing in health care. Later on, I realized that it was rehabilitation medicine that was missing. From the very beginning, I was not interested only in curative medicine. Rather, I was interested in the preventive, diagnostic and rehabilitative aspects of medicine. I saw many patients with spinal cord injuries and disorders, brain injuries and disorders, and polytrauma just lying in bed, suffering avoidable complications. Too often, they were dying prematurely. There was not a single rehabilitation physician in the country [of Nepal] to manage their issues. This was the driving force for me to become rehabilitation physician.
What were the challenges you faced to become a specialist in rehabilitation medicine in Nepal?
The challenges I faced were:
- There was no post graduate training available in Nepal to become a specialist in rehabilitation medicine.
- There was no funding to go abroad to obtain training and specialty certification in Physical Medicine and Rehabilitation (PM&R).
- PM&R was not even recognized as a specialty by the Medical Council of Nepal. (Fortunately, this has now changed.)
- There was no national level rehabilitation hospital in Nepal to work in after completion of training. Even now, none of the university/medical colleges and hospitals have a PM&R department or a rehabilitation medicine unit in Nepal.
Please tell us about Spinal Injury Rehabilitation Center and the work that is done there. When did it open? How many patients are seen there? How is it supported?
The Spinal Injury Rehabilitation Centre (SIRC) is a 51-bed non-profit, charitable inpatient and outpatient facility inaugurated in 2002. It is the only facility specialized in spinal cord injury (SCI) care in Nepal. We provide holistic and comprehensive rehabilitation utilizing an interdisciplinary approach led by a rehabilitation physician. SIRC has medical doctors, diagnostic facilities, physiotherapy, occupational therapy, nursing care, psychology, social service, peer counseling, recreational and sports activities, vocational training, wheelchair maintenance and an orthotic workshop, all under one roof. Until very recently, this was funded entirely by donations and fundraising activities, without government support. More recently, some government funding has finally been granted, but about 30% of the running cost comes from patient charges and we still have to have a fundraising program.
What challenges do persons with disabilities face when living in Nepal?
The challenges include:
- A lack of affordable, quality health care and education.
- Challenges in finding dignified employment opportunities (and training) and livelihoods.
- Environmental and attitudinal barriers (social stigma). In rural areas, there may be hills and mountains, with no roads. In urban areas, there can be rather unfriendly infrastructure as well.
What keeps you busy/busiest these days?
Being a medical director and consultant physician, I have been very busy with inpatient and outpatient consultant work, as well as multidisciplinary ward rounds. I am also very busy as a speaker or resource person in different SCI conferences at home and abroad – especially in this region. Now, I find myself becoming increasingly involved in research, training activities at SIRC, planning a PM&R residency, administrative work, and strategy and policy making for both SIRC and the SCI system of care in Nepal. In my very limited free time, I enjoy being with my wife, our one-year old daughter, and our families and friends. I also enjoy music and reading.
What are some of your goals, for your career and for the field of rehabilitation in your country/region?
My goals are:
- To continuously improve the quality of care for people with SCI in Nepal, including their meaningful reintegration into their communities.
- To help SIRC become a national and regional leader in SCI medicine and rehabilitation.
- To lead the Nepalese Association of PM&R.
- To start a PM&R residency training program in Nepal.
- To strengthen the role of rehabilitation in our health care system and at to have at least one specialized SCI unit in all seven provinces of Nepal.
- To strengthen collaboration and continued medical education in the field of SCI medicine and rehabilitation.
Tell us something about yourself that would surprise us.
I am the first and still the only registered PM&R physician in Nepal! I am not only a practicing physician, but also leading a 51 bed spinal injury rehabilitation centre with more than 300 inpatients with SCI per year. People can hardly believe that someone like me, who has a physical disability, could serve the country after a disaster like the 2015 earthquake.
Tell us about a memorable experience you have had as a doctor.
At the time of the 2015 Nepali earthquake, I was doing my residency in Dhaka [Bangladesh], but returned within three to four days after the earthquake with my wife and another colleague to serve the country’s needs. Every day, I managed around 150 patients with severe SCI with the team. In the evening and night time when we had electricity, internet and phone available, we used to discuss one or two cases everyday with ISCoS colleagues, especially from the SpiNepal group of Drs. Peter Wing and Claire Weeks. I particularly remember a 34 year old woman with a mild head injury and an unstable fracture-dislocation at L1-2, who was intact neurologically, but in severe pain and 34 weeks pregnant. After four weeks of careful management, the baby was successfully delivered by caesarean section and a spine fixation was done. Both mother and baby were healthy and safe. I still remember the crying and screaming of patients who had psychological stress with each aftershock, sometimes occurring every five to 10 minutes, when they were inside the building. We therefore took all the patients outside the building, provided temporary shade, and provided medical, nursing and rehabilitation care outside the building in the shade. I also remember that the doctors used to use an office in the building to view imaging, provide consultations or have meetings. After government officials visited and inspected the building, they did not allow us to return to this office because they had determined that it was a most unsafe place due to dangerous cracks caused by the earthquake. We never imagined that we could also become the victims of aftershocks, and we then changed our office to an area outside, under some shade.
Are there any places you have never visited that you hope to visit in the future?
I would still like to visit the major rehabilitation hospitals in the United States such as Spaulding Rehabilitation Hospital, Rehabilitation Institute of Chicago [now Shirley Ryan AbilityLab], Rusk Rehabilitation Institute and Kessler Institute. I would also like to visit the Stoke Mandeville Hospital in the United Kingdom. I would also very much like to revisit the University of British Columbia and GF Strong Rehabilitation Centre in Vancouver once again with my family.
Who are the person(s) and/or organization(s) you would most like to thank and why?
There is such a long list of people and organizations who have helped me throughout my career. I could not have achieved what I have without the support of my family and friends. The SOS Children’s Village family where I grew up supported me through medical school. Kanak Mani Dixit, a well-known journalist and editor in Nepal, who established SIRC in 2002, and many of his board members (especially Dr. Anil Bahadur Shrestha and the current board chair Prachanda Bahadur Shrestha) have been amazing sources of support and encouragement. Ms. Esha Thapa, the executive director of SIRC for many years, and who currently heads its parent organization, developed SIRC from its humble beginnings in borrowed space to the highly respected and still growing institution of today. Drs. Peter Wing and Claire Weeks, with the help of the SpiNepal contributors, supported me throughout my PM&R residency, and also showed me the field of SCI medicine and rehabilitation. My professors in the PM&R department at Bangabandhu Sheikh Mujib Medical University allowed me to return to Nepal following the 2015 earthquake. I am grateful also to Stephen Muldoon of Livability, ASCoN and ISCoS for financial and other material support, as well as for the encouragement that has come from so many of the leaders and members of these organizations. Many thanks are also due to the Canadian Physiatrists Research and Development Foundation for sponsoring me to visit two exceptional Canadian rehabilitation centres and to attend the resident review course they hold every two years. Finally, the team in Melbourne sponsored my visit to Royal Melbourne Hospital for further SCI medicine and rehabilitation training there after the Nepali earthquakes.
Member Spotlight: Mohmmad Rami Al-Ahmar
August 13th, 2018
Dr. Mohmmad Rami Al-Ahmar holds a position of Physiatrist & Spinal Injury Consultant in the Jordanian Royal Medical Services at King Hussein Medical Centre in Amman, Jordan. Among his many activities, he is a member of the ISCoS Educational Committee; the representative for the Middle East and North Africa region; founder of the Middle East North Africa Spinal Cord Injury (MENASCI) network; executive member of the Jordanian PM&R Society; vice president of the charitable Jordanian Spinal Cord Injuries Society; a World Health Organization liaison officer for the Eastern Mediterranean Sub Committee; and chief or member of many committees at his local medical center. He has been member of the scientific and/or organising committees for many international conferences. He has been invited as a key note international guest speaker in Jordan, United Arab Emirates and Qatar. Among his other honors and accomplishments, he is a recipient of a United Nations Medal in 2008 (Medal of Administrative Competence); and a winner for best oral presentation for research on bacterial strains in pressure ulcers at the ISCoS/American Spinal Injuries Association joint meeting in Montreal, Canada in 2015. Dr. Al-Ahmar acquired his MBBS from Damascus University in Syria in 2000. He completed residency in Physical Medicine & Rehabilitation at the Jordanian Royal Medical Services in 2008. He completed a spinal cord injury fellowship in 2012 at the Midland Centre for Spinal Injuries at the Robert Jones and Agnes Hunt Orthopaedic Hospital in Oswestry, UK.
What inspired you to specialize in physical medicine and rehabilitation (PM&R) and spinal cord injury (SCI)?
PM&R is a relatively new specialty in my region, and this is what attracted my attention. I am always ambitious to experience new fields and helping people with disabilities inspired me. During my residency program, I encountered so many patients with SCI. Unfortunately, not every rehabilitation doctor could educate patients about everything they needed to know, so it was up to the patients to know and discover what needed to be done. Managing the difficulties after SCI became my passion. During this process, I came to realize how happiness comes from giving rather than receiving. Helping patients take care of the practical things, manage emotions, and to have as good a life as possible is my aim now!
Please describe your fellowship experience in the UK. Did you encounter any difficulties, challenges or surprises during your studies and clinical work there?
I was lucky to have met Professor Wagih El Masry two times in Jordan (in 2008 and 2011). He offered me the opportunity to join him at the Midland Centre for Spinal Injuries (in Oswestry, UK), where I familiarized myself with all aspects of SCI management. In actuality, my fellowship went smoothly, as I was well prepared by a senior colleague who received his training at Stoke Mandeville Hospital. In addition, I had been diligently studying SCI management for years before the fellowship.
Please describe the current status of PM&R and spinal cord medicine in Jordan. How many training programs and specialists in PM&R and spinal cord medicine are there in Jordan?
In Jordan, PM&R started in 1980s and now there are residency programs at three institutes: the Jordanian Royal Medical Services (JRMS), the Ministry of Health, and Jordan University. All must obtain a (Board) Certificate of Specialization, which is issued by the Jordanian Medical Council. We are now around 80 board-certified physiatrists. There are only four doctors now who are specialized in the management of SCI.
Please let us know more about the King Hussein Medical Centre and its rehabilitation center.
King Hussein Medical Centre (KHMC) is a military medical compound of six hospitals. The Centre is affiliated with JRMS, a wide network of hospitals in different provinces across the kingdom of Jordan. JRMS provides health care for the military and their families, as well as civilians. The Jordanian Royal Rehabilitation Centre, opened in 1983, is one of the hospitals in KHMC. It has a specialized SCI unit with a capacity of 30 patients. It is the only unit of its kind in Jordan and receives patients from all over Jordan and the Middle East.
What was the inspiration for the formation of the MENASCI Network which you founded?
Regional SCI Networks have been established in Asia and Africa. These networks have been proven to be effective and efficient in promoting cross regional exchange, learning, education, technical capacity development, support and research in the field of SCI management. MENA, which stands for Middle East/North Africa, is a region based on the same culture, religions and languages. It is a region for which a specific regional network was needed. After many professionals from this region expressed their wishes to be part of a network, the MENASCI network was announced and launched during my presentation at the last Pan-Arab PM&R conference held in Amman, Jordan in October 2017. This network aims to achieve similar goals to other SCI networks, but with a greater focus on the patient’s family and caregivers, who are the cornerstones of SCI care delivery in the MENA region, as opposed to western countries where patients are more independent. Other goals are translating materials and e-learning to be used by consumers and professionals, as well as adapting management to specific religious and cultural needs such as fasting, dressing and gender aggregation, as examples. Many steps are underway and many are still needed to fully activate this network.
Please tell us about the situation of persons with SCI in Jordan and in the Middle East and North Africa region. What is the situation with respect to accessibility, attitudes and durable medical equipment availability? Are there any challenges regionally that are unique to the area that you typically would not see elsewhere in the world?
All soldiers and their eligible family members and the majority of civilian patients who have sustained SCI are fully insured in Jordan and have the opportunity to be treated in the spinal unit at KHMC. They are covered for all their medical supplies, with the help of NGOs (non-governmental organizations), and are followed regularly in outpatient clinics, with the exception of those who have sustained SCI inflicted by others, such as in road traffic accidents or gun shot wounds. In richer Middle Eastern countries, specialized care and equipment are available. Wheelchairs are advanced and well-provided, but users may receive limited training in wheelchair skills, depending on the availability of occupational therapists and other professionals. Social barriers exist, including the hesitation of wheelchair users to use their wheelchairs in public places. Of interest in Jordan, there is a new Law regarding the Rights of Persons with Disabilities which takes into considration:
a. The respect for the inherent rights and dignity, individual autonomy, and freedom of choice for persons with disabilities.
b. The participation of persons with disabilities and their organizations in policymaking, drawing up plans, programs, and decision-making operations related to them.
c. Not to discriminate against persons with disabilities on the basis of, or because of, disability.
d. The acceptance of persons with disabilities as part of human diversity and difference.
e. The inclusion of the rights and issues of persons with disabilities into national policies, strategies, plans, and programs as well as the state budget.
f. Equality between men and women with disabilities in terms of rights and duties.
g. Equal opportunities for persons with disabilities.
h. To ensure the rights of children with disabilities, develop their abilities and skills, and enhance their inclusion and participation in the community.
i. To ensure that reasonable accommodation and accessible formats.
j. The removal of physical and behavioral barriers for persons with disabilities.
While some or all of these regulations are available in several of the countries of this region there is still great need for implementation and enforcement of the regulations in these countries . In addition, there are no federal standards or guidelines and no legislation regulating the accessibility of public buildings for wheelchair users in many countries. and in the other countries, there is need to implement the statutes and to enforce them. Accessible transportation is limited in most of the MENA countries. In Jordan, the Higher Council for the Rights of Persons with Disabilities is collaborating with the government, community and NGOs to solve these issues in the future. In North Africa and poorer countries, persons with SCI face many difficulties due to the lack of specialized care and accessibility. In our region, families and caregivers can provide too much help and interfere with patients regaining their independence and reintegrating into the community. As an example, manual wheelchair users are mostly observed to be pushed by a family member or a caregiver rather than propelling themselves. We badly need to change the perspective of the able-bodied towards persons with disabilities to accept them, and not to judge them based on appearances.
Please tell us about your most memorable patient encounter.
My most memorable patient is a highly intelligent but unfortunate young man, who was 14 years old when he sustained a SCI. There were family issues at the time and the cause of his injury is still not obvious. After he adapted to his paraplegia, we helped him return back to school as a home study student. When he turned 17 years old, he gained a scholarship at the King Abdullah School for Excellence to join the engineering college. Unfortunately after one month of college, he developed Stevens-Johnson syndrome after he took antibiotics for a urinary tract infection. It affected his eyes and he became almost blind. He told me that he would be okay with remaining paralyzed, if he could only see clearly again.
What professional and personal accomplishments are you most proud of?
The professional and personal accomplishment which I am really most proud of is being a member of JoSCIS, the Jordanian Spinal Cord Injuries Society. This is a charitable NGO which was established by one of my seniors for people with SCI. I joined JoSCIS in 2011 and became an executive committee board member in 2014. In 2018, I became the vice president. My colleagues and I do a lot of volunteer work to support people with SCI in society through education, social activities, solving practical problems, and being available for contact for help with any medical, personal or psychological needs.
Who would you like to thank?
Humbly, I would like to thank my mother who always lights the candles when they are off, my wife, my two sons Laith and Hani for standing by during all the busy days and nights, my Institute JRMS, my teacher Dr. A. Otom who trained me, Professor El Masry who inspired me to think globally, and finally Mr. Aheed Osman who introduced me to the ISCoS Educational Committee and continues to always support me.
Member Spotlight: Guillermo Gómez
June 21st, 2018
Mr. Guillermo Gómez is a graduate of the University of Buenos Aires (Argentina), where he studied physical therapy. He extended his studies through hospital rotations in Europe to gain additional expertise in neurological and spinal cord injury rehabilitation. He has taught physical therapy as faculty at Maimonides University in Buenos Aires and in numerous other professional settings. He is an active member of the ISCoS Educational Committee. He founded and is the director of "Kreativa Rehabilitación," a facility in Buenos Aires which provides rehabilitation services to persons with various conditions including SCI and other neurological pathologies.
What inspired you to become a physical therapist?
Well, I played football in my youth, so I had some experiences with physical therapists due to ankle and knee injuries, which inspired me.
How did you become focused on physical therapy for persons with spinal cord injury (SCI)?
Unfortunately, a family accident guided my future as a professional. A very close cousin got a SCI playing rugby at the age of 18 years old. At that time, I was already a physiotherapist with some experience with this type of patient, but this event guided me forever. Patients with neurological problems and especially SCIs became my passion.
How and when did you first become involved with ISCOS?
Fortunately, I had the opportunity to visit a hospital in Toledo, Spain dedicated to SCI treatment. I was there for a month, in 2012. I learned about ISCoS there and immediately contacted Lisa Harvey, to tell her about my wish to be involved with a project to help in my region, Latin America. Lisa opened the doors to ISCoS at the time and I wish to thank her very much.
Please tell us about the state of physiotherapy and rehabilitation for persons with spinal cord injury in Argentina. How does it compare to the situation in other countries in Latin America? Based on your observations during your travels, how does it compare to countries in Europe and elsewhere in the world?
It is a challenge.
First, let me describe my perspective. I have been very active in Latin America and I am committed to improving the welfare of people with SCI in my part of the world. Nowadays, I am Executive member and the South American regional representative for the International Network of Spinal Cord Injury Physiotherapists (SCIPT). I am a member of the ISCoS Education Committee. In these roles, I have embraced the task of identifying physiotherapists in each of the countries in Latin America that are treating people with SCI and/or have a strong interest in SCI. To try to achieve my goal, I have traveled to multiple Latin American countries to meet physiotherapists and connect them into the SCIPT Network.
I think in some Latin American countries, the situation is "critical" regarding physiotherapy professional training for SCI rehabilitation. In Argentina and some neighboring countries (Brasil, Chile, Uruguay), at least, we have the possibility of providing training and SCI workshops. There are some congresses and ISCoS regional activities as well. It is lacking, however, in many other parts of Latin America, where the training and quality of SCI rehabilitation is quite behind the rest of the world.
I have travelled and visited some hospitals and SCI units in Europe (Toledo, Barcelona, Bilbao, The Netherlands, Belgium, Germany), and many colleagues and other people have asked me about the differences between Europe and Latin America. Well, I always give the same answer. To summarize, we (in Latin America) may lack infrastructure and the best equipment. Our resources are minimal in many cases. But we have our bodies and our hands. Through hard work, we will be the best professionals that we can be and provide the best care that we can. I am optimistic about the future.
What professional and personal accomplishments are you most proud of?
Humbly, I am personally proud of my achievements since my student days. It is not easy to study in our region, it requires a lot of effort. Ongoing development as a professional is also difficult. I've also built my own business, "Kreativa," and I own space to pursue my passion, the treatment of spinal cord injuries.
Please tell us about "Kreativa Rehabilitation."
It is my dream, my personal project, and my team... and it is a real! We are Kreativa, around 80 people working together to bring the best out of us for our patients. We have a director, coordinators, office personnel, doctors, physical therapists, and occupational therapists, among others, working hard to rehabilitate persons with SCI.
What are the greatest obstacles and/or challenges that you have faced in your career?
To be honest, sometimes I feel alone. But many people have supported my efforts and made me stronger to continue with my passion for SCI rehabilitation. I am a fighter, and I try to insert physiotherapy in all of the possible activities, congresses, workshops, etc., that involve SCI treatment; that is my fight.
Who would you most like to thank and why?
My family especially my wife who allows to me to travel to all of my congresses and workshops.
I would also like to thank ISCoS, all of the members of the education committee, Stephen Muldoon, and especially Lisa Harvey; she is my guide and an example to follow.
What interests do you have outside of work? What do you like to do on your days off from work?
I love to listen to music and I am a disc jockey. I like to play golf and football with my friends. I enjoy going to the cinema and going out with my wife, Flavia, and my two little ones, Facundo and Micaela.
Member Spotlight: Fiona Stephenson
May 17th, 2018
Ms. Stephenson studied both nursing and midwifery at the Royal Devon & Exeter Hospitals (UK) and holds additional qualifications in education (University of Westminster, UK) and international community-based rehabilitation (Queens University, Canada), as well as postgraduate diplomas in management (Institute of Management, London) and quality assurance. She is studying for a Master's Degree in Health Sciences at The University of Southampton (UK). Her career has included work with the Royal College of Nursing, including the International Reference Group, International Committee, Nursing Continence, Nursing Neuroscience, Education and International Forums. She was a Core Member of the World Health Organization (WHO) Rehabilitation Medical Teams and Spinal Cord Injury (SCI) Cell (Emergency Medical Teams) Working Groups. She helped to create and publish the WHO guidelines on the minimum standards for rehabilitation emergency medical teams responding to a sudden onset disaster (2017). She worked extensively in SCI healthcare capacity building in Haiti: for “Hope, Health Action" (formerly known as the Haiti Hospital Appeal - HHA) and Healing Hands for Haiti; and in Nepal: the Spinal Injury Rehabilitation Centre (SIRC) in Sanga. She is a founding member of the Haiti SCI Working Group and remains its international coordinator since its inception in 2010. In 2016, she became a Fellow of the Royal College of Nursing, achieving the Royal College's highest award for her contributions to the art and science of nursing. In 2017, Ms. Stephenson won the Cavell Nurses Trust International Impact Award and was a Nurse of the Year finalist (Nursing Times UK).
Currently, Ms. Stephenson is working as the Registered Service Manager at The Livability Spinal Injury Centre in the UK. She has been assisting in the set up of the new spinal injury centre in the heart of the Dorset countryside, which concentrates on ‘real time rehabilitation’ for people who have sustained a SCI. The aim is to assist people in reintegrating to the community in a supported, but realistic and pragmatic fashion, away from a typical hospital environment. The facility is set in 350 acres of wetland, woodland and heathland. She is responsible for the centre’s physical site, as well as the staff and people that the organisation supports. She is particularly involved in the recruitment and training of staff.
Ms. Stephenson has been an active member of the ISCoS Education and Disaster Committees and is assisting in the implementation of The ISCoS Nurse Committee (in progress). Outside of ISCoS, she is co-founder of The International Network of SCI Nurses, which now has over 500 members from all over the world. The network is involved in sign posting and training nurses internationally in SCI care. To date, Ms. Stephenson has volunteered in countries such as Mongolia, Madagascar, Nepal, Tanzania, Botswana, Haiti, India, Bangladesh, Indonesia and Jordan. In 2018, her volunteer work will take her to Sri Lanka, Mauritius, Zambia and Myanmar to provide training related to SCI nursing care.
Please tell us about a great success story you've been involved with in your work and travels.
I volunteered to respond to the Haiti Earthquake in 2010 with a UK/Haitian charity. There, I helped to create the first dedicated SCI unit in Haiti (with Haiti Hospital Appeal) and outpatient rehabilitation clinic in Haiti (with Healing Hands for Haiti). I helped to train the first SCI peer support worker in Haiti. I am really proud to say that all the patients that we cared for are still alive - 8 years later. In the poorest country in the western hemisphere, this is no mean feat. In 2010, we went from zero to 15 patients with SCI in two days, which soon went up to 25. Over 80% of those admitted had massive, grade 4 sacral pressure injuries that went down to the bone. These were healed conservatively by the Haitian nurses carrying out a wound care regime that I implemented. We carried out 3 and 7 year follow up studies that were presented as posters at ISCoS. I am so proud of everyone’s achievements. I regularly get feedback from some of the former patients: having babies and becoming employed. It is not all roses though. Haiti is a tough place to be.
Please tell us about your experiences working at the Spinal Injury Rehabilitation Centre (SIRC) in Nepal. Were there lessons learned in Haiti that you were able to apply in Nepal?
Immediately following the earthquakes in Nepal in April 2015, I supported SIRC from the UK. Given my skill set in disaster management in low and middle income countries, I was then deployed as a member of the UK Emergency Rehab Medical Team – a UK Government initiative. I served in country at SIRC, which is just outside Kathmandu, for over 18 months. Part of my early work involved rapid health care capacity building at SIRC to accommodate the substantial increase of patients with SCI following the earthquakes (from 38 to 200 people with SCI). This was an unforgettable time. I will always remember the incredible support provided by the local peer counsellors to the survivors of the earthquake. I have a vivid picture in my head of fifty plus people doing their stretches, yoga and music therapy together.
I created a register of international SCI specialist volunteers and organised them to support the local nurses, physios, doctors, psychologists, occupational therapists, and wheelchair technicians. Initially, the main focus was recruiting regional SCI specialist volunteer teams from nearby countries, and then to expand internationally. Countries in the region are culturally similar, more likely to speak the same languages and have similar styles of care and understanding regarding resources. Neurology and urology nurse specialist positions were introduced to the team, and proved to be extremely helpful. I am particularly proud of all the local nurses, as they significantly limited the incidence of urinary tract infections, fecal incontinence and pressure injuries. This standard of care has been maintained since then. I used and enhanced systems that were developed following the 2010 Haiti earthquake, including telephone follow up support. A questionnaire was developed to holistically address the needs of patients after hospital discharge. The questionnaire covered areas that included mental health, skin integrity, bladder and bowel management, equipment availability, transport and social integration. We monitored our results and the audits showed consistent improvements.
Supporting the staff and patients in Nepal was very different to my work in Haiti. Nepal already had an established SCI centre at SIRC. The Nepali culture is also totally different. The country is politically more stable and has a stronger health care system. There is also a lower incidence of violence. After almost 3 years of experience in Haiti, I became very aware that a quick visit and input for a week or two could be extremely counterproductive and disruptive to the local staff, if not managed effectively. I learned that it is so important to have consistency and continuity. In Nepal, specialists did also visit for a week or so, but with specific purposes in mind, and on the whole, this worked very well.
What interventions, e.g., medications, equipment, or education, do you feel have the most practical impact on improving the lives and health of persons with spinal cord injury in low resource settings?
Education. The “training the trainer” approach. Education empowers local health care professionals to provide support to people who have sustained a SCI within their local healthcare system/infrastructure.
What are your favorite moments of your career so far?
Gosh, they are so varied, to be honest. Each day is a new experience! I love the work I am able to do in low and middle income countries, as I do feel that I am able to share knowledge and skills with my colleagues.
What have been your favorite experiences related to ISCOS?
Meeting like-minded people. I really feel that the people I have met are part of the SCI family. I am very proud to be part of this. I love the camaraderie.
What keeps you busy/busiest these days?
ISCoS activities, SCI nursing activities, helping to set up the Livability Spinal Centre, and expert witness work.
Where are you traveling next? Where will you be traveling in the next few years?
France, in July for the International Society of Physical and Rehabilitation Medicine Congress. Australia, in September for ISCoS. Zambia, for AFSCIN (the Africa Spinal Cord Injury Network). Haiti. Myanmar, in November for the Asian Spinal Cord Network Congress. Nigeria, by personal invitation to provide SCI nurse training. And South America, hopefully to assist with SCI nurse training in the next year or two.
Please tell us about a skill or skills that you have that would surprise us.
I had a string of polo ponies and played polo for fifteen years in the UK! And I worked with the most ‘winningest’ polo player in the world for two and a half years, travelling to the USA, Mexico, Argentina, China and through Europe. I also have a Heavy Goods Vehicle driving license, for 17.5 tons.
Who is the person(s) you would most like to thank and why?
My mother, who encouraged me to go into the nursing profession and my family and close friends who have unconditionally supported me whilst working and living in low and middle income countries such as Haiti and Nepal.
I am also indebted to the local healthcare professionals in the countries I have visited, who have embraced the knowledge-sharing opportunities.
Member Spotlight: Dr. Noor Bismillah
April 5th, 2018
Dr. Noor Bismillah graduated medical school at the University of Malaya in Kuala Lumpur, obtaining a MBBS degree in 1996. She also completed her postgraduate studies at the University of Malaya, obtaining a Master of Rehabilitation Medicine in 2005. From 2006 to 2008, she served as the head of the Rehabilitation Department at Hospital Raja Perempuan Zainab II, the state hospital of Kelantan state in northeastern peninsular Malaysia. She next served as the head of the Rehabilitation Department at Queen Elizabeth Hospital, the state hospital of Sabah state in Borneo, from 2008 to 2011. From 2013 to 2017, she served as the head of the Spinal Rehabilitation Unit at Hospital Rehabilitation Cheras (HRC) in Kuala Lampur. HRC, which opened in July 2012, offers comprehensive outpatient and inpatient rehabilitation medicine services and has 166 beds. It is the first hospital of its kind in the Southeast Asia region. HRC, an initiative of the Ministry of Health, Government of Malaysia, is designed with an emphasis on energy efficiency, green spaces and therapeutic landscapes. It is locally known as the “Hospital in the Park.” Dr. Noor Bismillah currently continues to serve as a rehabilitation physician on the Spinal Rehabilitation Unit at HRC. She has been a member of ISCOS since 2015.
How did you get interested in the field of rehabilitation medicine in general and spinal cord injury (SCI) medicine specifically?
My interest in rehabilitation medicine started when I was still in secondary school. I really wanted to do more for my late father who had a stroke at the time. The interest grew even deeper when the health clinic where I was working was selected as the first health clinic in Malaysia to run a community outreach program for disabled children. From there on, my enthusiasm to learn more about rehabilitation medicine grew even stronger. When I learned that there was a Master of Rehabilitation Medicine programme being offered by one of the local universities (University of Malaya), I immediately seized the opportunity and sent my application. To my utmost happiness, I was accepted into the 4th batch of postgraduates enrolled into this programme and started my training in 2001. I was first introduced to SCI medicine during this programme. Since then, I have continued to have a deep interest in learning everything I can about SCI medicine and wanting to help as many patients with SCI as I can.
What have been your main areas of interest within the field of SCI/rehabilitation medicine?
I have an extra interest in the management of neurogenic bladder in SCI because I just love to see how the team comes together to contribute so much to this. As a team, we can design the best bladder management programme for each patient to get the best results. We have a saying here that, “Together each achieves more.”
Please tell us about the situation related to medical care and rehabilitation of persons with SCI in your hospital and in Malaysia in general.
I am very grateful to have been able to see and contribute to the development of rehabilitation medicine services in Malaysia. After I graduated from the Master of Rehabilitation Medicine programme in 2005, I served in two government state hospitals. During that time, rehabilitation medicine was still very much an unknown to most of the hospitals in Malaysia. I consider myself to be very lucky to have had the opportunity to personally experience the challenges in starting a rehabilitation medicine service in each of the hospitals where I worked. When I first started the service in one of the hospitals, I did not have my own chair to sit on or my own table to do work. However, with the strong support from hospital administrators and my colleagues, the services progressed very well. After about 4 years, we managed to open a rehabilitation ward and clinic for our patients. Now, Malaysia has a total of 86 rehabilitation physicians serving in 16 government hospitals, 7 university hospitals, 6 private hospitals and one social security rehabilitation centre.
Management of rehabilitation patients in Malaysia in general has its own unique challenges. As Malaysia is a multiracial country, not only do we manage patients from various races, but we also have to deal with various languages, dialects, cultures, religions and socioeconomic backgrounds. The key points to successful management are respect for all the differences and treating each patient as a special individual who deserves the best treatment regardless of social background.
What improvements in the lives of persons with SCI and other disabilities in Malaysia have you seen over the years?
Over the years, with the expansion of rehabilitation medicine services in Malaysia, I see less and less of our patients suffering from medical complications related to SCI such as pressure ulcers and joint contractures. On the other hand, I am seeing more and more of our patients able to live independently. A large number of our patients have been reintegrated back into the society and have become productive members of the community. Some of our patients are now serving the community through their original professions despite the various physical disabilities that they have.
What accomplishments are you most proud of?
I am very grateful to have been able to initiate a spiritual support programme at my current workplace. This program is aimed at encouraging and helping patients participate in their spiritual activities. By this, we are hoping to be able to help them achieve optimal spiritual health and ultimately reach a more holistic recovery at the end of their rehabilitation programme. Under this programme, we organise a number of activities which include providing a disabled-friendly praying area for patients who are wheelchair dependent. We also provide the necessary equipment for our patients to perform their prayers and guide them on how to perform the ritual despite the physical limitations that they have. We also provide free food for suhur for patients who are well enough to fast during the month of Ramadhan. This spiritual support programme gives me the utmost satisfaction in my management of patients with SCI because I have a chance not only to manage their physical disabilities, but also to help them become more holistically healthy.
In my 12 years experience of working as a rehabilitation physician, the most interesting experience was when a newly paraplegic patient requested of our team to help him prepare to perform Hajj within three months of admission to our hospital. It was such a great challenge for us, but with a combination of the patient's strong determination, the team's tireless efforts and excellent networking with Malaysian Hajj Institute (Tabung Haji), we managed to fulfill his wish and he successfully performed the Hajj as planned.
Member Spotlight: Dr. Federico Montero
February 1, 2018
Dr. Federico Montero attended medical school at Universidad Autónoma de Guadalajara and Universidad de Costa Rica. His medical internship was interrupted by a motor vehicle accident resulting in a spinal cord injury (SCI). Subsequently, he changed his plans from becoming a pediatric surgeon to specializing in SCI. He underwent postgraduate training at the National Spinal Injury Centre at Stoke Mandeville Hospital, Rivermead Rehabilitation Centre and University of Costa Rica. His career highlights include Coordinator of the World Health Organization [WHO] Disability and Rehabilitation Team; and Director General, National Rehabilitation Center, Costa Rica. He was a member of the Editorial Committee of the journal Paraplegia (now Spinal Cord). Currently, he is teaching in the postgraduate training program in physical medicine and rehabilitation (PM&R) at the University of Costa Rica. He is also currently the President of the Red de Organizaciones de Personas con Discapacidad de Centro América y el Caribe (REDODICEC, http://www.redodicec.org).
How did you become involved with ISCoS (formerly IMSoP, the International Medical Society of Paraplegia)?
Soon after my injury, I considered the fact that the rehabilitation offered and expectations for a person with SCI at that time in Costa Rica were not very favorable. Thanks to the help of my cousin, a physician working in Phoenix, Arizona, who found out about a good option there, and with my parents’ support, I was able to travel and be admitted to the SCI unit at Good Samaritan Hospital. It was there where I had my first contact with IMSoP. Invited by Dr. John Young, the Director of the SCI unit, I was able to attend a scientific meeting on SCI organized in that city, while I was still a SCI patient. On my return to Costa Rica, I worked as a general doctor for about a year, then managed to get a scholarship through the British Council to initiate my SCI training at the National Spinal Injuries Centre, Stoke Mandeville Hospital in the UK. During my time spent at Stoke Mandeville and working closely with Dr. Hans Frankel, I had the opportunity to attend various scientific meetings and meet well respected people in the field of SCI medicine, including many members of IMSoP.
What improvements in the care and lives of persons with SCI in Costa Rica have you seen over the years?
After my training in the UK, I returned to work at the National Rehabilitation Center in Costa Rica, which had recently opened its doors to inpatients. All patients with SCI who were admitted to the general hospitals were later transferred to the Rehabilitation Center. Most of these patients had all sorts of complications. Most persons with tetraplegia, in fact, died during their general hospitalization before transfer to the Rehabilitation Center, while others died at the Rehabilitation Center due to these severe complications. This situation provided me with the opportunity to rapidly organize a small SCI unit, staffed with personnel properly trained for the comprehensive management of patients with SCI. Subsequently, all patients with SCI admitted to other hospitals were sent to our unit and the development of complications reduced significantly, including a 0% incidence of pressure sores. Currently, despite the fact that the Costa Rican health system is very good, there are significant limitations in providing patients with the required assistive devices and resources for neurogenic bladder management. Nonetheless, the unit has strengthened, and most patients return to their homes fully rehabilitated. Many continue to follow up in the outpatient clinic. Unfortunately, sometimes complications appear, due to poverty and all its consequences.
What do you wish other physicians and health care providers in your experience knew about SCI medicine that they do not seem to understand?
This represents a very frustrating reality within the medical field. Despite the fact that Costa Rica has a very inclusive health system, as well as high quality and dedicated health professionals, knowledge about proper SCI care is still limited, even amongst many specialists. Most patients with either traumatic or non-traumatic SCI are well managed during the very acute stage, but not so much afterwards if they have to remain in the general hospitals. So, I wish that the specialists working with those patients could be more aware of at least the relevant pathophysiology of SCI, as well as the potential complications associated with these injuries. At the least, nurses should be properly trained in the prevention of pressure sores, proper positioning and proper bladder management.
Please tell us about your most memorable encounter with a patient.
When I first arrived at the SCI unit in Phoenix, my English was not very good. The nurses put me in contact through the telephone with another patient who spoke Spanish to translate. I must say that there was not much that I could understand from this gentle Mexican-American fellow, but his explanations relaxed the nurses enough to proceed with their routines on the recently graduated young doctor. I met the Mexican-American fellow personally the next day and we became very good friends. He had a long-standing SCI and was in hospital due to pressure sores. He used to work in construction before his injury, and lived in Yuma, Arizona. This great and easygoing man, who weighed more than 300 pounds those days, provided me with the information and support I needed at the time. He saved me a lot of money I would’ve had to pay for consultations with a psychologist.
What professional and personal accomplishments are you most proud of?
When I got married, Dr. John Young, who was the Director of the SCI unit at Good Samaritan Hospital, where I was treated after my injury, gave me Sir Ludwig Guttmann’s textbook as a wedding present. In the book, he wrote, “…it has been a privilege and joy to know you. I have no doubt you are destined to follow the lead of Sir Ludwig bringing health and pride to your paralyzed countrymen.” Despite the fact that I did not have all the resources I would have liked in order to do my job better, to provide patients with all the resources they need and deserve, I think that Dr. Young wouldn’t feel disappointed.
What differences have you seen in the care and lives of persons with disability in the developed world versus the developing world?
I have had the opportunity to personally undergo the rehabilitation process in a developed country, and participate in various activities in the USA, UK and others. This has helped me to understand the situation of people with disabilities in developed countries. As a person with a disability myself, working in Latin America, a region where social and economic differences are so visible, and in a public hospital, I have also been quite exposed to the reality of people with disabilities in developing countries. More recently, I had the opportunity to work for the WHO in Geneva for almost 5 years, where I traveled to many countries in Africa. I went to rural areas and met people with disabilities, and my knowledge and understanding about the situation of people in developing countries deepened even more. I have seen large gaps in the care and lives of persons with disability throughout the world, and even within the same country.
What keeps you busy these days?
I am currently retired from regular hospital work, but continue as a member of the Post-Graduate Committee on Medical Rehabilitation at the University of Costa Rica. I am in charge of the SCI course for the PM&R residents. I am also collaborating with ISCoS to improve access to information and promote knowledge of SCI in the Latin American and Caribbean Regions. In this respect, we have already carried out activities in Guatemala and Honduras in 2017. We have plans to be in Uruguay this March, and possibly Ecuador in October. With the help of a Costa Rican translator and other Latin American colleagues, we have translated the ISCoS eLearn SCI modules into Spanish. I also support some PAHO [Pan American Health Organization] and WHO activities in the region and I am currently the President of a regional network of Organizations of People with Disabilities called REDODICEC. So, my sociopolitical involvement for the rights of people with disabilities also keeps me quite busy in my country and regionally. I also enjoy a piece of land in the countryside in a small town called San Mateo.
Do you have any advice for those starting out in SCI medicine or rehabilitation medicine in general?
The specialty is one of the most complex and, at the same time, a rewarding one. We work with a population, although truly more empowered over the last 30 years, still is one of the most segregated, with no access to basic needs and services in many parts of the world. Rehabilitation, as well as SCI medicine, require deep knowledge and understanding of many other areas of medicine. Our field goes beyond many other specialties, however, because of the struggle of the people we work for, which goes beyond the rehabilitation process. We may provide them with the first tools for recovery, but the specialty also commits us to be allies of our patients and of all people with disabilities, in their struggle for a life with dignity and enjoyment of all human rights.
Who is the person(s) you would most like to thank and why?
My wife, who unfortunately died not many years after we married, and my son, who was born in England during my training. They both inspired me to work and study very hard during my training in SCI. My wife, a nurse, accompanied and helped me in the development of the SCI unit in Costa Rica and the training of personnel. My son continues to provide me with satisfaction and happiness!!