Updated hour-by-hour schedule for 3-day course on critical care nursing

Executive summary

In 2013 somebody asked to see the schedule for the course. it’s a reasonable request, but – I had not written it down. so I dashed off a reply. Two weeks ago I updated the schedule to reflect what we actually do. Here it is.


“Bringing Critical Care Nursing Education to the Himalayas”

Critical Care Nursing Assessment and Advanced Cardiac Life Support (ACLS) Training

Joe Niemczura, RN, MS, (Principal Faculty, CCNEPal )


Program Schedule Day One

Date /Time Topic Notes (⃝ = place for mini-lecture)
0900 – 0915 Registration (prior registration advised, sign-in) Give teamwork handout, ask early attendees to read while waiting for late® arrivals. Give 15 minutes for late arrivals due to traffic etc. Go around room and ask each participant to tell their name and introduce themselves to group (language assessment)
0915 Overview of course. Assessment of class knowledge and demonstration of successful teamwork (expected class outcome)

Discussion of elements of critical emergency response, with demonstration by instructors about what successful team will look like after three days.

Teamwork handout.

Group exercise in giving receiving, and repeating orders. Use typical med orders that will appear later in class.

Go over where to stand when you arrive at an emergency, division of tasks etc

0930 Four steps in CPR As on page eight of protocol. Interactive exercise. Use toy balls for manikins, also use music “ Ready” and “Resum Firiri”
1000 Bag resuscitator Positioning airway, E-C method. Take turns. Double E C method. Use handout of bag resuscitator. Time to disassemble and reassemble bag-valve-mask.
1030 Onliest six rhythms The six basic rhythms and the two ABCD surveys for ACLS. (NRS, brady, tachy, asystole, VF, VT) Intro to flash cards.

Importance of VFib. 2-step VF drill.

1045 Division of tasks on arrival. IV, O2, monitor, saO2.
  Electrical safety “I’m clear, etc” – and pulse check.
1045 Divide into groups Choose group name(s)
1100 First drill. Explanation of rotation system ROUND ONE of scenarios.Focus on communication skill.

Scenario number one. (VF – NSR)

  debrief Gather together for report from assistants.
1230 lunch
1300 Cardiac conductive system. Electrical activation cycle. Students will be required to draw the four answers from memory at beginning of day two

Four questions on quiz – chemical cycle, electrical cycle of one cell, PQRST, conductive system with intrinsic rates.

Lecture first, then assisted by others to supervise personal guided practice of interpretation in small groups with personal feedback and recitation

There will use of handout with examples of rhythms in which student is guided in interpretation.

1345 How to read ecg paper Large and small boxes, hash marks, six-second sections, etc.
1400 six-step method to interpret ECG rhythms using handout. Guided practice using this method. Common problems with monitoring. Choice of lead. Where to place on chest etc. artifacts and problemsolving. The grid handout. How to perform each of the six steps.

ecg dance

  Break for chiya  
1430 Rhythm strips, using system
1445 How to use scenario and how to use protocol. For this we will use the nine scenarios from American Heart Association handouts. (students will be given a personal copy of eight-page protocol sheet.) Over next days we will go over these group by group. Short lecture then break up into groups for

ROUND TWO of guided small group practice with personal feedback and repetition of skills while being videotaped. Use of smartphone video for feedback and critique.

TWO monitor/defibrillator units are requested for this. Scenarios will include universal protocol.

Also will use five bag-valve-mask devices

  Four possible outcomes of defibrillation

NSR, Asystole, recurrent VF, PEA.

Go over steps to respond to each.

5H and 4T (depends on audience)

  Short review of morning teamwork skills. ROUND THREE of small group teamwork skills. Start with review of scenario number one. Then go to four possible outcomes. break up into groups and rotate between stations.
  Review of eight-page protocol handout from AHA, being on same page (define) ⃝ AHA handout.
1400- 1500 Acute coronary syndromes. MONA.

Page 5.

How to assess awake victim.

30 and 90 minutes to strepto or cath lab respectively.
1500- 1600


Use effective teamwork and communication skills for successful intervention in critical nursing situations ROUND FOUR of small group teamwork, assessment of chest pain victim, followed by MONA and possible VF.


1600- 1615 Description of next days training. Get mobile numbers, explain about phokso. For second day, each group brings in a phokso.

Day Two

Date /Time Topic                Speaker
0900 – 0930 Introduction with quiz on cardiac conductive system from first day. Niemczura, team.
0930 – 1000 Rhythm strips. Description and lab of cardiac anatomy
1000 – 1115 Dissection using en bloc heart-lung assemblies of goats (from butcher shop) in small groups, with discussion of how to relate this to nursing assessment and support of goals for medical and surgical intervention. ⃝ Hands-on. For this we need tables in classroom.
1115- 1230 Page 5 part two. Acute M.I., twelve-lead ecg, chest pain protocol. How to look at ST segment change. Pharmacology of rx of chest pain according to protocol. ⃝ chaat paati exercise ROUND FIVE mona. Small group practice. Handout.
1230- 1315 lunch  
1315 – 1400 Review of atrial rhythms, junctional rhythms. further rhythm practice using sample strips, guided in small groups. ⃝ The grid, and atlas handouts.
  Steps in defibrillation ⃝ Interactive group practice exercise of ten steps. Quiz on day three.
1345 – 1400 Quick review of teamwork, then break into groups again. Students take turns being team leader and team member ROUND SIX small group practice. Review of previous days scenario and teamwork, using different group members than Day One. Now focusing on chest pain protocol
1400- 1500 Bradycardia protocol. Definition of hemodynamic impairment. (Bp, chestpain, sweatiness). Reminder: find best actresses.
1500-1545 Scenario of chest pain with bradycardia. ROUND SEVEN
  Introduction to tachycardia scenarios ⃝ Morphine overdose. discussion.

⃝ Treatable causes game.

1545 – 1600 Cleaning up class room and preparing for final day  

Day Three

Date /Time Topic                Speaker
0800 – 0830 Overview of day, quiz on steps of defibrillation.  
  Depending on availability of defibrillator, guided practice using steps of defibrillation.

Depending on availability of monitor, practice using the grid to interpret ecg via eyeball method.

Sync button. ⃝ Additional steps in synched current.
0830 -0930 Review of tachycardia scenarios with demo. ROUND EIGHT practice focusing on specific tachycardia scenarios.
  Final ecg practice using paper handouts and grid.
0930- 1030 Special scenarios related to unusual conditions. Review of second ABCD survey to determine less-frequently occurring scenarios ( hypothermia, drug overdose, renal failure, weedkiller overdose therapy, etc.) Large role play.
  Family counseling issues. ROUND NINE special scenario, also learning to go flexibly from one page of protocol to “put it all together” in megacode
1030 – 1100 Debriefing.  
1100 -1230 Practice with bag resuscitators ⃝ game for speed
1230- 1300 lunch  
1300- 1400 Final practice round ROUND SEVEN – final scenarios in which groups are expected to flow between all pages of AHA protocol sheets with no advance warning or hint of what the problem is.
1400-1430 Small group discussion, in Nepali, self-guided. Gather equipment at this time.
1430-1500 Final exam Large group, names in hat.
1500 Presentation of certificates  

Prior to class – students will be given large electronic file on ecg rhythms for study, also protocol handouts.

Notes about classroom setup – we need a classroom that can hold about thirty people, preferably with flat floor ( not a sloping auditorium) and no carpeting. Ability to sit at tables so as to work with handouts and sample strips. Whiteboard or blackboard with colored marker pens and or colored chalk. A computer monitor for powerpoint is ideal but not necessary. When we break out into small groups, it is preferable to use adjacent spaces so as to keep noise level down.  We are flexible about this. Screens can be used.

Notes about equipment: we need two monitor-defibrillator units to which we will attach our 2 AT-34 rhythm generators. If you have CPR manikins those would also be good but not necessary. Three or four IV poles with IV bag and tubing (these can be nonsterile ones that would be otherwise discarded) and bag-valve-masks and airway equipment. If you can bring two or three patient stretchers that would be good but if not we can use tables instead. An Overhead projector.

Students bring a smartphone if they have one with video capability. Their own pen and notebook. Wear clothes suitable for activity including kneeling on floor and bending. Bring a small blanket to lay on floor if worried about getting dust on clothes.

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All Nepali nurses who want to go to UK need to read this

Summary: even if you do not read all the way to the bottom, click here to go to the FaceBook page for The Center for Medical Simulation Pvt., Ltd and click on “like.”  Also, subscribe to this blog for further entries on simulation learning in Nepal.

“Simulation Learning” has jumped to the forefront of education for health professions in Kathmandu.

In BBC news from August 27, 2014, there was the following article: (look for the sections in BOLD – I added those for emphasis)

Nurses and midwives who complete their training in hospitals outside Europe will now face shorter tests to check they are fit to work in the UK.

The Nursing and Midwifery Council (NMC) says its plans include a computer-based exam and tests in simulated clinical scenarios.

And the regulator says these will replace the minimum three months of supervised practise currently required.

But nurse leaders warn they need more details to confirm checks are adequate.

At the moment nurses and midwives who have trained overseas make up about 10% of the workforce registered to work in the UK.

Around 1,000 nurses a year come to work in the UK from outside the European Economic Area – the majority from Australia, India or the Philippines.

‘Agile process’

The NMC says one of the reasons behind the change to assessments is that the current supervised placements – which can last between three months and one year – are not fast enough to meet demand.

The regulator says the system is “not agile enough for employers who need to recruit quickly.”

And the experts report applicants have had difficulties obtaining places on the programme, as they are in short supply.

The new tests, planned to start in the autumn, consist of two parts:

  • A computer-based multiple choice exam, discussing various situations
  • Observing applicants during simulated healthcare scenarios
Nurses and midwives who have trained overseas currently make up about 10% of the workforce

Similar checks have already been adopted by other healthcare regulators, according to the NMC.

The regulator says: “This will ensure the hundreds of nurses and midwives who trained overseas and wish to practise in the UK are assessed in a a proportionate and robust way, in order to protect the public.”

Jackie Smith, the NMC chief executive, said: “The new system will not replace the need for employers to ensure that the staff they recruit display the behaviours, skills and knowledge necessary for the specific role to which they are recruited, and provide further support and development as required.”

‘Dedicated workers’

Janet Davies, executive director of nursing at the Royal College of Nursing said: “Health care in the UK relies on the hard work and dedication of many nurses who trained overseas.”

“These proposals may well form part of a more robust and consistent mechanism for ensuring that nurses who work in the UK are equipped to practise in the UK.

“However, we need to know more about how nurses will be evaluated as part of this system before we can judge whether or not the system is adequate.

“Whether nurses come from the EU or the rest of the world, it is vital that employers are recruiting them for the right reasons and supporting them when they get there.

“Too often, nurses are recruited from overseas to fill short term gaps and given inadequate support to care for patients well.”

Official figures suggest some 67,000 nurses and midwives who completed training outside Europe currently hold NMC registration.

This adds to the present workforce of more than 600,000 nursing and midwifery staff who have trained within Europe and gained registration with the UK regulator.


summary: even if you do not read all the way through, or if you do not look at the links highlighted in blue, go to the FaceBook page for The Center for Medical Simulation and hit “like,” so you will get future announcements.

News: You won’t be able to get a UK license unless you can pass a simulation learning exam.

Right now, there are only two places in Kathmandu where nurses can learn about simulation learning.

the first is CCNEPal. This is a small NGO that provides one specific course – Cardiac Life Support. In this course, CCNEPal uses techniques borrowed from the American Heart Association to focus on lifesaving skills including ecg, protocols, Basic Life Support, and teamwork. CCNEPal trained 534 nurses in 2013 and CCNEPal is on track to train 600 more in 2014. CCNEPal has posted a number of videos of their project on YouTube. Click here to see the longest one. We do scenario-based training, and small group work is a big part of what we do.

Simulation learning usually is a surprise to Nepali nurses. Click here for a short video in Nepali Basha in which one nurse tells her reaction. Or maybe click on this one…. or this one … Or just find somebody who took the class and ask them.

Announcing The Center for Medical Simulation

The second is The Center for Medical Simulation, Pvt.,Ltd., which will be having it’s grand opening in late September. The Center for Medical Simulation, Pvt., Ltd is now undergoing the final stages of construction, but it is a state-of-the-art facility on  par with anything on Planet Earth. I have toured their place in Dillibajar and It’s going to be a fine location for learning.

disclosure: I do not have any financial stake in Center for Medical Simulation. I am serving as a volunteer consultant for them on an UNPAID basis. My opinion is my own and has not been influenced by them other than the fact that I have discussed with them their plans. For me, I have worked with simulation in both USA and Nepal, and I am writing this because Center for Medical Simulation is going about it in the right way.

The Center for Medical Simulation is on the fourth floor of this buiisling in Dillibajar, right where the second row of windows is open.

The Center for Medical Simulation is on the fourth floor of this building in Dillibajar, right where the second row of windows is open.

The Center includes classroom space and also will have a “3G Sim Man” – the fanciest patient simulation manikin ever devised. But even more importantly, the Center will be managed by a nurse who is familiar with simulation learning and who got a BSN in USA (even though she is Nepali.) Srijana Kansakar will be guiding a trained staff to help nurses learn how to achieve in simulation, and – to enjoy it. Each simulation experience will be carefully designed from an educational perspective to give you confidence and skills.

Medical Training too

back to CCNEPal and our mission. Our goal is to advance the quality of medical care during critical situations, and to train both nurses and doctors. CCNEPal courses fit the needs of Nepal, but they do not lead to “official certification” from the  American Heart Association (it’s expensive due to the equipment). Obviously, we want the highly-skilled professionals to stay in Nepal, but for many young doctors the career path is to learn in USA, UK or Australia for awhile before returning. The word is, they will compete for abroad residency better if they have ACLS certification and are able to do simulation. for that reason, The Center for Medical Simulation is offering courses leading to official certification in ACLS, BLS and other areas. The Center for Medical Simulation has invested the funds needed to provide an “official course.” And yes, they will charge a fee.

Grand Opening

The Center for Medical Simulation will host short talks about their mission, during their Grand Opening in late September, 2014. Click here to get added to the Center for Medical Simulation FaceBook page. You will be able to get info on the Grand Opening and other events.


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CCNEPal Updated Schedule as of August 21 2014

Hi -

Book Update

My novel, The Sacrament of the Goddess, will be published in Nepal in September, around the 17th when I get back from the Terai. I invite all my friends to celebrate with me here. I want to organize a street party with Everest Brass Baja!  Go to the FaceBook page for the book, and hit “like” if you want updates.


I was looking through my records. I have taught 15 sessions, for a total of 443 certificates handed out. hooray!


from Sept 3rd to the 16th I will be in Bharatpur at CMS. I will do three 3-day sessions for nurses there, and a two-day session for doctors.

Two-day sessions in Maharajganj?

Sept 19th, 20th and 21st – a three-day session at a hospital in Kathmandu.

Dasain -

I will be taking holiday during Dasain.  I’ll be back Oct 15th.


Oct 17 & 18th – 14th annual meeting of Cardiology Society of Nepal, Hyatt Regency Hotel.

Oct 19,20 & 21st; then Oct 22,23 & 24th – Lumbini Medical College, Palpa.

Oct 26 & 27th – two-day version of course for MBBS docs in Dillibajar.

October 30, 31 and Nov 1st – Global Hospital, Gwarko.

Nov 2014

Nov 2,3, and 4th; then again Nov 9, 10 ,11th – TUTH School of Nursing M. Sc. students.

depart for USA Nov 16th.

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focus on Bag-Valve-Mask Devices in Nepal hospitals

This will be a short post.


CCNEPal always goes over bag-valve-mask devices as part of the 2-day and 3-day class. We have decided to amplify the material we give students on this subject. We did some internet research and wrote an eight-page document about these important yet overlooked tools.

Acknowledgement of source material

Let me say, right up front, the primary source was a brochure by the Laerdal Corporation. This was excellent, but the original was written in such small text that it did not photocopy well. Also, most Nepal hospitals use less expensive bags from a Chinese source that does not supply a manufacturer’s brochure along with their bag.


and where would we be without YouTube?

There are several videos. One describes the procedure for assembling the bag-valve-mask.


It turns out, this is a popular topic. here is a good one.

There is a list of about fifty videos that describe various aspects.

If you want a copy of this eight-page document, please send an email to joeniemczura@gmail.com


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Updated Schedule for CCNEpal 2014 as of July 21, 2014

Where have I been?

Just got back from two weeks in the Terai. Mostly Bharatpur but also Biratnagar. I loved the people in Biratnagar, though I was so busy teaching I really never left the hotel. I taught “double session” there – one group of thirty from 0800 to 1 PM; then an hour off before teaching the next group of 25 from 2 to 7 PM.

At the end of each day I was tired.

CNE Planet

This is the name for a group that provides Continuing Education for Nurses, located in Biratnagar. They were my hosts. I was excited to learn about their mission.  find them on FaceBook at https://www.facebook.com/groups/309310719106884/

What about the Terai?

I think every foreign medical volunteer needs to go to Terai. For at least part of their trip, and not just to ride an elephant.

Fifty per cent of the population of the country lives in the southern valleys that make up the Terai, and now we have a half-dozen medical schools and teaching hospitals there, all of which are dedicated to improving the health of the population. Some medical schools in Kathmandu talk about sending their graduates to the rural areas; these schools in the Terai are actually doing it.


There have been cancellations and additions to the CCNEPal schedule since I last wrote.

July – session in Butwal is cancelled. I will happily make a Road Trip to Butwal/Bhairawha at some future time but I need a host in each location. I don’t go to any place unless the in-charge people invite me.

July 29th and 30th; then again July 31st and August 1st – two, two-day sessions for MBBS docs in Bharatpur at CMS. I am still experimenting with the best way for the 2-day version for docs. it’s been well-received so far. this time we will have a smaller group.

LNC Sessions in August

August 3, 4 and 5; 10,11 and 12th; these two sessions are fully enrolled.

August 17, 18 and 19th – there are still seats available for this session at LNC campus in Sanepa. to register, go to LNC Library with 1200 nrs fee.

August  24, 25 and 26th -still seats available for this session at LNC campus in Sanepa. to register, go to LNC library with 1200 nrs fee.

August 6,7 and 8th; 13, 14 and 15th – sessions at Said Memorial Hospital in Kalanki. there may be a few seats available, send me an email. joeniemczura@gmail.com  due to small size of classroom we limit the number of enrollees.

open dates in August in KTM – I would be willing to add a session on August 20, 21 and 22 in KTM Valley. I would also possibly add a session on August 27, 28 and 29th. please send email to joeniemczura@gmail.com

Terai again

Sept 3rd through 16th – I will be in the Terai again at CMS in Bharatpur. 3,4 and 5th; 10,11 and 12th; 14, 15 and 16th for 3-day nurses sessions. we will do a 2-day MBBS session at CMS September 7th and 8th.

open dates in September in Terai – I could add a 3-day session the 18th, 19th and 20th in Terai. I figure that once I am there I might as well be there, as opposed to coming back and forth from KTM all the time.

Sept 25th to Oct 10th – is Dasain and Tihar. do you seriously think anybody will take a class at that time? I don’t think so either!

Oct 12,13 and 14th; 19th,20th and 21st; 22nd, 23rd and 24th; a series of 3-day sessions at Lumbini Medical College Teaching Hospital in Palpa district. also, a 2-day session for MBBS docs Oct 16th and 17th (tentative).

Nov 6th in Dulikhel, I have agreed to speak at a conference on evidence-based practice.

Nov 15th – the Nepal Society of Critical Care Medicine is hosting the First Ever national conference on critical care. I plan to go.

Nov 16th – I return to USA for a few weeks holiday with my daughters. I expect to be back in Nepal about January 2nd.



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Shouldn’t we read about the real Nepal?

The Sacrament of the Goddess is about Nepal, but not the Nepal you usually read about. This book is about Nepalis, not Western mountain climbers. Nobody climbs Everest. Everybody here is trying to lead a good life.

Nepal is a fine place to go on a Buddhist retreat, but taking a class is not the only way to learn about Buddhism in this country. There are people here who were born into Buddhist families – how do they live their lives? the story in this book will reveal that mystery…..

When I attempted to win this from First Reads I thought it was a biography of a missionary doctor. I am not quite sure how I got that so mixed up. Okay , so I didn’t do too bad, it wasn’t a biography, but it was about a missionary doctor and the village hospital he chose to serve at. It was very educational. I know more about Buddhism and Hinduism than I learned in my World Cultures class. It was great the way Kali showed Matt (and us) the similarities and differences.. It was also a love story, neatly woven through the years. It is a story about friends, family, and community. An excellent book to read for enjoyment, or even for a world Religions course.

this is the most recent review. to read other reviews and to order the book, click here


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doing ICU care in Bharatpur, Nepal – dispelling the myths

quick advert -

buy my second book about health care in Nepal. It’s a novel that draws upon my experiences here. It is about contemporary Nepal, and nobody in the book climbs Mount Everest or goes through a harrowing accident involving a glacier.

I just finished four days of training the staff of Chitwan Medical College Teaching Hospital in Bharatpur, Nepal. If you include the thirty people from last year, I have now trained about 140 nurses and doctors and medical students in Cardiac Life Support at CMC, the most of any individual hospital in the country.

Bharatpur is a medical nexus for the Terai. People come from long distances to seek medical treatment here. more than fifty per cent of the population of Nepal lives in the Terai.

I think there is a myth or fantasy that somehow, this part of Nepal consists only of thatched roof buildings and that they are only capable of delivering elementary care in a collection of dirt-floor huts made of mud-brick.  If you read the statements of people in Kathmandu, (whom I will not name) they seem to say that nobody outside Kathmandu can possibly know what they are doing.

I have had the opportunity to spend time here, get to know people, watch them in action, and look at their physical plant and equipment.

IN SUMMARY:  they have modern buildings and equipment and they are offering a high standard of critical care services appropriate to the needs of the community. They do know what they are doing, here.

to see up-to-date photos, click here

I decided to take some photos. I love wordpress but this is not the easiest way to post photos, and so I am creating a photo album on the FaceBook page for CCNEPal.





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