1. Experience Of Telemedicine After 2015 Mega Earthquake Disaster At Spinal Injury Rehabilitation Centre, Nepal Author – Dhakal R, MBBS, MD resident PM&R, Dhaka Co authors – Gurung JB, Gyanwali S, Poudel MK

2. Background -  Recent ongoing development of a specialty called “Disaster Rehabilitation” has increased the importance of rehabilitation intervention during the immediate post-disaster emergency response  Natural disasters can cause significant numbers of severe, disabling injuries, requiring assistance from rehabilitation medicine experts  Telemedicine can be an ideal mode in places with inadequate health resources

3. Objectives  To identify the applications of telemedicine for medical rehabilitation during a disaster  To propose the use of this technology in the areas with a shortage of experts

4. Methodology  Prospective observational study  Experiences of the authors with telemedicine at spinal injury rehabilitation center(SIRC) during the earthquakes in 2015.

5.  Colleagues from ISCoS Most with post-earthquake rehab experience Daily Skype/ Viber “Rounds” with Dr. Raju/Dr.Jas History, Examination, Lab reports/Imaging sent in advance 1-2 cases per day

6.  A total of 81 earthquake spinal cord injury (SCI) patients were admitted within four weeks of post-disaster time at SIRC  Around 15% of complex and critical cases were discussed with SpiNepal team through regular online rounds by Skype, Viber, E-mail, Telephone

8. 24 yrs woman, L1-2 fracture-dislocation with 34 weeks of pregnancy – 2 nd DOA at SIRC History, physical examination and investigations sent..

9. Her perineum had not been easily examined; a catheter was in place. Her BP was somewhat low at 90/60 or less. We expressed concern that if she lies supine she may lose return from her IVC and suggested side lying. We requested that you request an obstetric consultation to assess maturity of the pregnancy. better that she has a caesarean section than be allowed to go to term and perhaps precipitously begin labour. Dr. Scott also assessed the images

10. Dhulikhel hospital for an Obstetrics consultation blood pressure issues during change on posture Pain management and regular neurological assessment Advice from Dr Rhonda: continue pregnancy to 37 weeks then consider Caesarean section to avoid her going into labour because of the unstable nature of the vertebral injury. Dr Scott Paquette has reviewed the imaging and added that he would probably instrument 2 levels up and two, with a postero-lateral fusion, and "would likely decompress the fracture level if there was any real neurology.

13. Discussed with some pediatric colleagues and experts. Right now, we suggest: - Start a clean intermittent catheterization routine, and check urine for infection if she is symptomatic - Start a bowel routine as below, with daily suppository - Establish baseline blood pressure by monitoring regularly (4 times a day), from which then you can determine whether dysreflexia may be occurring. - In children, dysreflexia can manifest as crying, irritability and sleepiness. In under 5 years of age, they may NOT have headaches or piloerection

14. - Begin some therapeutic play to work and use upper body/hands; learn weight shifts - Get her to work on breathing and coughing – whatever works – blowing bubbles, singing songs, deep breathing… - Careful skin monitoring for pressure sores - Begin to work on getting her upright sitting – watch for signs of fainting, work on sitting balance, and then transfers. Find a manual wheelchair to fit her and ensure appropriate pressure relief cushion

15. - Hip x-rays at some point soon will be needed, as she will develop scoliosis and is high risk for hip sub-luxation and you need to establish her baseline - Continue with bracing likely 3 months total, but still looking for surgical opinion if she needs stabilization Cheers, and feel free to REPLY ALL to this for ongoing discussion – Colleen

16. What’s working/ wasn’t Good case summary by Doctors Very slow internet Poor voice quality, disconnections Phone OK, but no images Incorrect diagnoses from acute hospitals Inadequate imaging at acute hospitals, but free Repeated after shocks and lack of safe space Despite problems, it helped with both patient care and resident teaching.

17. Advantages / Drawbacks Instant assistance No visas, immunizations No travel difficulties No physical threat No drain on limited resources Fits with other efforts Doctors only No time for overall rehab planning Limited number of doctors available No hands on Small number of cases Problems with record- keeping and “hand-over”

18. Take home message Tele-consultation through various means such as telephone, e-mail, and video conferencing can improve the quality of health care by – Aiding in diagnosis and management of patients To train health care professionals

19. Accessibility of specialty and subspecialty expert care can reach, thereby reducing the morbidity and mortality after SCI and eventually increasing the quality of life Information technology and modern portable communication devices should be incorporated in disaster preparedness and post-disaster SCI rehabilitation. Systemic incorporation of tele-medicne system at SIRC would be ideal to minimize the cost, improve the quality SCI care by online consultation at SIRC and also its satellite centre.

20. Acknowledgements – SpiNepal group – esp. Peter and Claire for their everyday online Tele- consultation and distant ward round Canadian PM&R/SCI expert – Coleen, Rhonda, Joan and others Canadian neurosurgeon – Scott American Pediatrician – Prof. L Vogel

21. Thank you Spinal Injury Rehabilitation Centre Bhainsepati, Sanga, Kavre, Nepal Tel: 011-660847 / 660848 Email: spinalinju@wlink.com.npspinalinju@wlink.com.np Website: www.sirc.org.npwww.sirc.org.np A PROJECT OF SPINAL INJURY SANGH NEPAL