Himalaya Sunrise, Nepal
Neurocritical Care in Nepal By Gentle S. Shrestha, MD, FACC, EDIC, FCCP
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Nepal is a landlocked nation in South Asia
bordering China to the north and India to
the east, west, and south. It has a population
of 26.4 million with an area of 147,181 km2.
Nepal is a low-income country with a gross
domestic product per capita of USD 682.20,
as of 2016. Currently, 23.6 percent of the
population is below the poverty line.
Neurocritical illnesses like traumatic brain injury (TBI) and stroke
are among the major causes of morbidity and mortality in lowincome
nations like Nepal. Severe TBI disproportionately affects
low-income and middle-income countries (LMICs) and features
poor outcomes when compared to developed nations. LMICs
bear about two-thirds of the global burden of stroke, and the
incidence is increasing. Central nervous system infections like
meningitis, encephalitis, and cerebral malaria are highly prevalent.
Tuberculous meningitis and Japanese encephalitis cause significant
morbidity in this part of the world.
Delivery of effective neurocritical care services in Nepal is hindered
by lack of ICU beds, significant limitations of resources, lack of
trained manpower, lack of pre-hospital care, and lack of awareness
among the general public. There are a total of around 500 ICU
beds in the entire country, with only a few ICU beds offering
advanced monitoring, mechanical ventilation, 24-hour laboratory
facilities, and organ support. Most of the ICU beds are located in
major cities, depriving a major proportion of the population from
critical care services.
Due to lack of health insurance policies, the cost of patient
management has to be borne by patients’ families. Most patients
are unable to afford the cost of critical care services. Pre-hospital
care is poorly developed, and so is pre-hospital transport of
patients. Geographical challenges together with frequent natural
calamities like landslides and earthquakes often impose significant
challenges on the transportation of sick patients, sometimes
making it almost impossible.
Public awareness about early features of stroke and the significance
of timely management of neurocritical illness is lacking.
Combined with poor pre-hospital care and transport, most
patients with neurological emergencies seek health care services
too late, thus potentially contributing to poor outcomes. Only
a handful of patients with ischemic stroke receive thrombolytic
treatment due to limited availability, cost, and late presentation.
A significant lack of trained manpower plagues Nepal. The
country has a limited number of trained intensivists, neurologists,
and neurosurgeons. Trained neurointensivists are almost nonexistent.
Critical care medicine is a new specialty in Nepal. At
present, most critically ill patients are being treated by doctors
and nurses with limited training and knowledge. Few tertiarylevel
teaching hospitals offer three-year super-specialty programs
like DM in critical care medicine, DM in neurology, and MCh in
neurosurgery. The number of experts produced every year is too
small to meet the needs of the nation.
To enhance the accessibility of critical care for patients across the
nation, the government of Nepal plans to establish tertiary-level
ICUs in each of the zonal hospitals (Nepal has 14 administrative
zones) and at a reasonable cost of care. Public awareness about
neurological emergencies needs to be raised, so that early health
care seeking behavior increases. If patients would present early,
even limited, cost-effective interventions could prevent progression
of disease, decrease the need for advanced and costly critical care
services, and potentially improve outcomes. Vaccination against
meningococcus and Japanese encephalitis can help prevent these
common neuro-infectious diseases. Recently, the government
of Nepal has launched a vaccination campaign against Japanese
encephalitis at the national level.
Several national societies and organizations have been formed
with the aim of enhancing care of patients with neurological
illness, raising awareness, and training and updating health
care workers. The Nepalese Society of Critical Care Medicine
(NSCCM), established in 2010, aims to develop critical care
services across the country. It embraces over 100 members from
various specialties. In 2015, NSCCM joined the list of NCS’ global
partners and is a member of the newly formed Asian chapter of
NCS. Established in 2008, the Nepalese Society of Neurosurgeons
(NESON) has over 50 members and publishes the Nepalese
journal of neurosciences tri-annually. The Nepalese Academy
of Neurology and the Nepal Epilepsy Society embrace health
care workers from various specialties that deal with neurological
illness, such as neurology, neurosurgery, psychiatry, and nursing.
All these societies conduct regular CMEs and conferences with the
aim to update members about neurological illness.
A group of experts have been conducting Emergency Neurological
Life Support (ENLS) courses in Nepal. So far, four courses have
been held, with the first in February 2015 also constituting the first
ENLS course in Asia. Conducted in different parts of the country,
the courses were well attended. Considering the limited resources
and the fact that most neurological emergencies are treated by
doctors and nurses with limited knowledge and skills, the creation
of simplified, cheaper courses tailored to the local availability of
resources and disease epidemiology is imperative. Collaboration
with and support from international societies and bodies will help
to develop neurocritical care in Nepal, thus saving more lives and
improving the outcomes of neurocritical illnesses.
Gentle S. Shrestha, MD, FACC, EDIC, FCCP, is Assistant Professor
at the Department of Anesthesiology, Tribhuvan University Teaching
Hospital Maharajgunj, Kathmandu, Nepal. Gentle is also very active
member of NCS and an invited guest writer for Currents.