How a doctor or nurse can prepare for a medical volunteer trip to Nepal since the April 2015 earthquake.


There is a surge of interest among nurses and doctors to volunteer in Nepal since the earthquake. I’ve been coming here since 2007 and I have some advice.

Specifically for Doctors: The Nepal Medical Council is still working. You absolutely must be credentialed to work in this country, earthquake or no earthquake.

First – Nepal is still an active disaster zone. The aftershock of May 12th   reminded the people of Kathmandu that it’s not over. Do you really want to do this?

I originally wrote this under the title “Twelve Steps to Prepare for Global Health Nursing” in May, 2011 and that version was published in the online version of Imprint, a publication of the National Student Nurses Association.

Your nursing skills are your gift to the world. 

This blog usually gets a hundred hits a day, but the stats zoomed off into the 800-hits-per-day region in the weeks following the quake. The drama and heroism of the earthquake captured the attention of the world. Relief workers and supplies poured in to Nepal.  As “Professional do-gooders,” it’s understandable that you want to help. No matter where you go, you need to prepare. Despite the urgency, there is no urgency – it will still be a disaster months from now.  These simple steps will guide you to make the most of your experience.

Learn about the “bubble.”

We all exist in an invisible “bubble” – an insulating set of comforts and expectations to make daily life easier and predictable.  The “bubble” consists of familiar routines and objects that make our daily life easy. It’s also a set of cultural assumptions, most of which are taken for granted. For example, whether the cars drive on the left side of the road or the right; the way a toilet operates; table manners; or the proper greeting when you meet a stranger.

Clever tourism promoters go out of their way to present a predictable packaged experience – “the bubble” – to insulate the traveler from the sometimes-unpleasant reality of life in other parts of the world. A trip to Nepal is off-the-beaten-path, and qualifies as “adventure travel” with unpredictable elements. When you combine travel and medical or nursing practice, you are going behind the scenes, to the places the usual tourist does not go, and meeting people in their turf, in settings not in the guidebooks. You will need to learn a whole new set of travel skills and it takes courage. Less than four percent of all travelers engage in adventure travel.

To use your nursing skills in Nepal requires a new set of skills to navigate daily life. If you have never visited any foreign country, you will be in for a surprise in Kathmandu.  The toilets are different and there is not always toilet paper. The food is not the same.  People don’t generally use washing machines (they wash by hand), and they certainly don’t drink the water. In a separate blog I described how the hospitals work. Things you take for granted, such as intravenous line setup, are not the same.

Here’s a list of things to do before you come.

Get the shots. Go to a travel clinic and get immunized. make sure you tell that that you will be working with sick people.

Choose an NGO. NGO stands for “Non-Governmental Organization.”  In Nepal, for a nurse, the very best is NurseTeachReach from Australia. They were here prior to the quake. Don’t go with a group that has never been to Nepal or that is vague about what you will do. Before the quake, there were some tours billed as “village health care” which essentially turned out to be trekking trip that handed out toothbrushes. Frankly, there were some groups that showed up in Nepal, claiming to their volunteers that they knew the country – that didn’t.

Backfill

The role of the foreign volunteer is mainly to “backfill” the less complicated care needs so the Nepali staff can focus on what they need to do. Be advised, the unemployment rate among “passed out” nurses in Kathmandu hovers at about forty per cent. Every volunteer nurse that comes here to do direct patient care is taking the place of a qualified Nepali nurse. The Army and Police got overtime pay for their work; the nurses did not.

An NGO will pave the way for you to use your skills to the maximum. Often, they will plug you into an existing program that will fit your needs, and also help you with in-country travel and such things as food shopping.

The W.H.O. has a longstanding embrace of the idea that USA is the “big brother country” of Central America and Africa. There aren’t that many Americans with experience here, by comparison. The Peace Corps pulled out during the Civil War and only recently returned.

Learn the language.  Take language lessons. This is the single most important long-range skill required for most global health experiences. Nursing depends on making a person-to-person connection and dealing with the patients face-to-face. If you are a doctor, they will often give you an interpreter; nurses don’t get that same perk. Your transition will be easier if you can  say hello, navigate the local bus system, and  order at a restaurant.

Meet somebody who is from Nepal. In the largest American cities nowadays, there’s always a South Asian grocery store, or one that sells Tibetan stuff. You can find small pockets of people from nearly every society on earth – this is an amazing resource. Use the internet or go to your local college and you can find somebody who is from Nepal. They can become a source of valuable information in all sorts of ways.  Before I left for my first trip to Nepal I found a Nepali language tutor by posting a small flyer on the wall of the only South Asian grocery store in Honolulu. She taught me about language and customs such as table manners and greetings.  Befriending a person from a different culture is a two-way street and has many advantages.  It is something we can all do even if we have no intention of leaving home.

Go camping.  Learn how to get by with fewer creature comforts than the typical American. If you have never prepared food using primitive equipment over a woodfire, or used a privy, this skill will open your eyes to the daily challenges faced by rural people all over the world. Start to walk or hike regularly – if the transportation system is poor, you may find yourself walking a lot more than usual. In some cultures, coffee is not a daily menu item; If you simply must have coffee every day, learn how to make it using a wire mesh filter.

Eat the food. This starts with going to a Nepali restaurant in USA if there is one nearby; but in many countries where cooking is the role of women, you can experience the role of women by familiarizing yourself with food preparation and the time it takes.

Read the literature of the country. Don’t bother with “Where There is No Doctor” – it’s a fine book but tells you nothing about hospital care. My favorite is Common Medical Problems of the Tropics. Start with the Lonely Planet tourist guidebook; even though the iconic temples will be closed for repair, these still include useful cultural tips and the elementary rules of etiquette. You can learn about religion, politics, gender roles, customs such as those surrounding funerals, and body language. I once met a nurse from USA that wanted to teach a hospice and bereavement course here – but she didn’t know anything about Hindu customs such as same-day cremation. She needed more homework.

Dress Modestly. This is a conservative country, and you need to respect the values. In Kathmandu, women may wear a short skirt, but in the rural areas (such as the epicenter zone) they will be very conservative. Do not show cleavage or anything tight that shows off your butt. The typical outfit of a relief worker these days is jeans and a T-shirt. See photo.

This called a "Kurtha Surual" and the front and back apron conceal the wearer's curves. This photo was taken in January in Palpa; in Summer it's cooler but the principle of modesty is the same. Also, you are less likely to get leeches in one of these outfits.

This called a “Kurtha Surual” and the front and back apron conceal the wearer’s curves. This photo was taken in January in Palpa; in Summer it’s cooler but the principle of modesty is the same. Also, you are less likely to get leeches in one of these outfits.

Here is a person you might be meeting:

Here is a person you may be meeting. (photo b a friend of mine who was in the earthquake-affected rural area.) She has a fascinating and wonderful cultural background. But she's more likely to trust and respect you if you dress modestly and respect her culture.

Here is a person you may be meeting. (photo b a friend of mine who was in the earthquake-affected rural area.) She has a fascinating and wonderful cultural background. But she’s more likely to trust and respect you if you dress modestly and respect her culture.

Read my two books about Nepal hospitals, The Hospital at the End of the World and The Sacrament of the Goddess.

Don’t bring toothbrushes. You can get them here, cheaper than in USA. Do bring textbooks. The language of instruction in nursing schools is English. Click here to read about donating books.

Read Nepal Newspapers on-line. MyRepublika is a personal favorite; Nepali Times has also gained respect for their excellent earthquake coverage.

Are you  an ACLS, BLS or PALS Instructor (or Regional Faculty?) there is one AHA ITC in Kathmandu and you should affiliate with them.

Use Social Media. Everyone in Nepal is on FaceBook. Every hospital and Medical School has a FaceBook page. Two groups with more than 10,000 “likes” each, are Nepalese Nurses and Nurses of Nepal. CCNEPal and NurseTeachReach are also on FaceBook.

YouTube. Here’s a playlist I made from all my odd videos of Nursing Education in Nepal.

Here is a truly excellent twentythree minute documentary about childbirth in Nepal.

Here is a playlist of hospital videos, mostly from Mission Hospital in Tansen

Plan for culture shock and re-entry shock. Study this link to University of the Pacific. Culture Shock arises from the inevitable comparison to your home. Re-entry shock is something that sneaks up on you – it happens when you return, expecting to take up your life where it left off, but realize that you have changed in unexpected ways. It is not unusual after a global health experience to feel disconnected from your home culture.  It is worse when you do some kind of hard-core medical thing in a Low Income Country. Every nurse needs to be aware of this phenomenon.

Minimize your baggage. I have friend who has led ten trips to rural Nicaragua. She blushingly confessed to me that she brought a blowdryer with her the first time. On each subsequent trip she learned what she did not need. Nowadays, she travels very lightly, with only as much as she can fit in a daypack, for a three week trip.

About students? This is not the place to bring students if they have never travelled outside the USA before. A newbie does better in some sort of cultural trip, such a Habitat for Humanity. Yes, they have to start somewhere; but – Costa Rica would be a better trip for a first-timer. Or maybe Ireland.

Plan to share from the beginning. We owe it to our fellow Americans to educate them about global health, and a firsthand account is powerful. Get a camera and practice with it before you go. Be advised, Nepal has strict rules about photographing patients these days without their consent. No matter how much you tell people, they will never understand what it was like unless you have photos when you return. If you buy souvenirs or artifacts, choose ones which tell a story about the daily life of the people. Keep a journal.

Learn about hospital and clinic standards. Many of the health problems are directly traceable to lack of public health infrastructure. There will likely be more problems with infectious diseases; and you may need to learn how the local providers deliver care even though disposable supplies may be limited or they may not have new equipment.

Skip the “Pearls” A common approach among young medical students is to focus on learning diagnostic zebras, such as leprosy or malaria. Medical care in Nepal is more than just being able to say you saw a case of visceral Leishmaniasis.  Learn about the social context of illness. Study poverty and malnutrition. Many hospitals operate a “feeding station” for malnourished people. Learn about the health  practices and about the health system.

No alcohol. We are still having aftershocks. This is not a party destination. If you disable yourself by getting snockered here, your team will be unable to respond appropriately to a challenging situation. You are a liability. Kathmandu is not a place where women go out at night unaccompanied. You can stay home in USA if you need to drink.

Practice “water discipline” and food sanitation. Clean water is something we take for granted. Food- and water-borne illnesses are the single biggest problem encountered in foreign adventure travel. In Nepal the water from the tap is unreliable. It is helpful to practice safe ways to use water which will become firmly engrained habits prior to the trip.

Are you going somewhere else? Even if the primary purpose of foreign travel is vacation and you are not planning to use your nursing skills, there are some things you can do. For example, if you go to the Caribbean, you can get “out of the bubble” by spending a half-day touring a local hospital. Often, somebody will gladly show you around even if you give limited notice. In Low Income Countries, up-to-date nursing textbooks are beyond the reach of local health care workers. Pack one with your luggage as a gift for the hospital library and you will contribute to local health care even if it in is a small way.   This sort of person-to-person experience does not need to be planned in advance.

Something to think about

Nepal has twentyeight million people, twice as much as the six-state New England region. If it were a US State, it would be #2, second only to California.

In summary, an experience in Nepal can be very rewarding, but to have the best success will require intensive preparation, and the time to start is now. We can benefit from adopting a global attitude, even if we never leave home.

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First-hand eye-witness description of nursing needs in earthquake-ravaged area of Nepal by a Nepali-American nurse


A #Nepal -American nurse reports from #Sindupalchowk after #Nepalquake

Firsthand assessment

This was on the FaceBook page of a friend and I thought it was newsworthy. Generally, the people doing actual earthquake relief are too busy to send reports back, and there is limited teleconnectivity in the rural area.

Note; Unita Magar, RN, MS is a nurse from Nepal who went to school in USA and now is in graduate school in New York City. I met her when I was on book tour for The Hospital at the End of the World in 2009.  (she rode the train for two hours to hear me speak). She is active in NANA – the professional nurses association for Nepali nurses in North America. Click here for their FaceBook page. There you will also find pictures.

In November, I met with NANA members in Jackson Heights, Queens New York ( the epicenter of Nepali neighborhoods in USA!)  and Unita brought me “panipuri take-out” – a very hospitable gesture.

NANA could not stay in USA

When the earthquake hit, NANA members did not hesitate. They spent some time gathering equipment, and got on the plane. Normally, it is not a good idea for Americans to just jump on a plane and go to a disaster area. NANA knew they had specific skills to offer.  ( the current President, for example, got her PCL nursing education from Bir Hospital) As you might imagine, their language skills are flawless and they come to Nepal with perfect cultural understanding as well as nursing background.  Nepal is not an easy country for foreign nurses. They invited me to join them on their relief mission, but I decided to continue my teaching.

Here is what Unita Magar, RN,  wrote ( I did not edit it, but added some formatting):

Our team went to thulo bhotang, sindhupalchowk and kalleri, dhading. All the villages in sindhupalchowk have been very much damaged, most of them down to rubbles – sad. We were able to see many patients in both regions. My heart breaks to see so many people losing their loved ones – orphans, widows, mothers who have lost their child/children …

My assessment so far:

1. Eating utensils: One of the young girls from dalit community who lost her mom and sister mentioned not having utensils to eat food, as they are buried in rubbles. So while distributing rice bags and other foods that is one area to keep in mind.

2. Schools and health posts have been badly damaged in most of these villages. That is another area of need. With no proper health posts, patients are not able to f/u with the the medical professional re: their wounds, upper respiratory problems and other health issues – wounds can get infected if not followed up. Medical teams come and leave in 3-4 days that is not good enough for continuity of care.

3. Most people have been displaced from their homes – educating public re: what type of houses to build is important. People were asking me what type of houses to build. Educating public on this will be very helpful.

4. Houses: so far people are using tarps for temp housing. Monsoon season is coming soon. This means people especially in mountains will need more stronger houses – jasta pata type to keep them dry.

5. Many kids are orphaned – putting them in schools will be important. It is so sad frown emoticon I wanted to adopt them all. At one instance I was trying to counsel one baini (young girl) who lost her mom and lil sister in earthquake and I could not hold up my tears. Tears rolled down my cheeks. Instead of me comforting her, she was telling me “please don’t cry, things like this happen.” One of the dai (young Nepali guy) said he will educate those 3 kids. Bless his heart. There are many young needy kids displaced by earthquake like this baini and her siblings. Many might get dragged into bad direction if not guided, so kids, especially girls will be important to focus on.

5. Elderly people: who are living alone by themselves. More chances of being malnourished due to lack of proper help and resources due to current situation in Nepal.

6. Women and dalit community – important to distribute food/shelter to them first when distributing goods. As they may stand behind allowing others to get the goods first due to Nepal’s cultural practices. Sometimes, they may not get anything because of that.

7. Important to use the locals from the region when doing any projects or distributing foods.

8. Going from house to house may mean everyone will get the medical tx and supplies. Some ppl maybe too weak, busy or disabled to even walk 15 minutes to use the available services. Going door to door is beneficial if u want to be more effective in your effort. We were able to reach out to more people when we went from door to door from village to village.

8. Counseling and psychological services – will be very much needed in Nepal. We saw many patients with c/o headache. This may indicate post traumatic stress disorder. One baini said to me she felt relieved after talking to me. She was afraid of sharing her thoughts with her neighbors as she was afraid they may gossip. Some people may feel comfortable sharing their thoughts with an unknown face to known face.

Everyone in the city and villages continue to live with some lingering fear of earthquake recurring again. It will take a while to overcome this fear.

9. Men in Nepal may have difficulty sharing their concerns and thoughts with others, thus holding their worries and loss/losses locked inside their minds. They may instead resort to drinking to forget their worries. This is another area of concern.

10. Some patients are in hospitals with no family members visiting them. We saw some volunteer bhais acting as a companion and advocates for these patients. There are quite a few patients like these in hospitals.

11. Hard hand gloves in villages for villagers trying to take out their belongings from the rubbles.

There is lot to be done. However, everyone is doing their best here in Nepal and abroad in any way they are able from taxi driver brothers to students to professionals, army, police to the general people in Nepal despite the fact that their families are also suffering. Salute to all of these kind souls

for foreign response teams

It is critically important, for all foreign response teams, to have somebody like Ms Magar  with them. She understands the cultural nuances of Nepal and can guide decisions. For example, the truly vulnerable persons do not always appear in public, at the front of the line, demanding help – they suffer alone and in silence. In the above, she is an articulate link between the ongoing social issues of  human trafficking, the depopulation of rural Nepal’s young men, and the coming famine.

The reconstruction needs are extensive. I am sure that NANA will continue to send money.  go to their site.

Prior to the earthquake, it was difficult to get young doctors and nurses to serve in these areas, and the Nepal government was actively supporting various schemes to do so. Since the earthquake, I have read various USA editorials about “rebuilding Nepal’s health system” and frankly, some of these were by International NGOs that had only a minor presence in this country before the quake. I have worked with Nepali people since 2007 and in a future blog I will throw in my two cents. Briefly, Nepal has twentyeight million people with about twenty medical schools, hundreds of nursing schools, and a system of hospitals in the private sector, some of which are quite new and modern. Most of the hospitals in Kathmandu survived intact; click here for more info on hospital damage assessment. The health sector has a history of extensive collaboration, and any International NGO that comes here, needs to know this. Resist sloganeering.

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CCNEPal calendar update May 16th – from Butwal, Nepal


CCNEPal whereabouts

In Butwal and Rupandehi district. I’m teaching at Gautam Buddha Community Heart Hospital in Butwal. This was not on the original itinerary but – things happen……

May 12th aftershock

The Government told all the schools to close for two weeks, after the May 12th event. Serious recovery and relief work is still going on in the hills. For me, this meant that three of my planned hosts agencies cancelled. I used FaceBook to send a message about my availability, and that’s how I ended up at Crimson Hospital then GBCHH. I did three three-day sessions in a row. I will add another session at GBCHH starting Sunday May 17th.

so my remaining time is

May 17th, 18th and 19th – GBCHH in Butwal.

May 24th, 25th and 26th – location TBA in Palpa.

May 27th – return to Kathmandu

May 30th fly out, to USA.

2015 summary

since January I have done 23 sessions. A total of 687 nurses and docs got a certificate. All but five were outside the Kathmandu Valley.

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what the nurses of Nepal need to know about cholera, part one May 13th, 2015


Diarrhea

Cholera is endemic in Nepal, along with other diarrheal diseases. There are small outbreaks but these are contained before they get to the epidemic stage.

Haiti had a cholera epidemic after the 2010 earthquake, and people are worried that Kathmandu will have one.

Zimbabwe also had a cholera epidemic, and it got worse than it needed to be, because the health care workers there abandoned their posts. When that happened, there were cholera germs everywhere. You can control cholera in a hospital setting as long as the cleaners are doing their job.

When we think of disaster relief, we think of the soldiers and police and rescuers. But when it comes to epidemic, the nurses are serving the country of Nepal. Click here for a patriotic display by Nepali nurses!  The nurses are doing their patriotic duty to help Nepal.

I’m going to post some links on cholera, so that everyone can learn more about it.

Start with this one, which is a cartoon about how it spreads. We need to keep the sewage away from the  drinking water.

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What every American volunteer nurse needs to know about hospitals in Nepal May 9th, 2015


Nurse’s Day update: if this intrigues you, take a look at my second book. It  was written specifically as an orientation to Nepal healthcare, in a readable way that also makes it a great “beach read” for nurses.

May 11th update Today’s Nepali Times featured a written assessment of the Nepal government disaster response by Mark Zimmerman, MD of Nick Simons Institute.  I respect and value his opinion, and I think every interested party  should read this. Click here.

This is specifically for nurses who volunteer to work in disaster relief in Nepal. If you are an American nurse thinking you can walk into a Nepali hospital and function, all by yourself, you will need to be very clever. I originally wrote this in 2011. It seems timely to reblog because of the earthquake. It is one of the appendixes to my first book, The Hospital at the End of the World.  The original was straight out of the book; this is now edited. Since I am the original author, I sought and received permission from – myself.

And if you want more pictures, The Hospital at the End of the World has a FaceBook Page with about 500, total.

Reblogged and updated from 2011.

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What is Different about Hospitals in Nepal?

The first three weeks at Mission Hospital were my orientation. It was overwhelming, but I plugged away at it. During this time there were many small details to learn. Here in no particular order are the differences between the ways that a nurse works in a Mission Hospital in Nepal compared to a hospital in the US.

Gloves

Gloves are recycled until they break. The gloves are latex. When they are soiled, the gloves are placed in a special bucket to be cleaned, re-powdered and recirculated. An employee of the supply department makes the rounds to collect the soiled gloves each day and bring a new supply.

The latex gloves are saved, and cleaned for re-use. Until recently, this was also the case with syringes; fortunately nobody I know of is cleaning and re-using syringes any more.

The latex gloves are saved, and cleaned for re-use. Until recently, this was also the case with syringes; fortunately nobody I know of is cleaning and re-using syringes any more.

hand hygiene

The patient rooms do not have a sink. When the doctors make rounds, there is a special rolling hand washing station on a wheeled tripod that accompanies them so they can wash their hands between patients. The charge nurse reminds the doctors as if she is a mother nagging the kids. Near the nurse’s station is a sink with a bar of soap and a fresh towel replenished each shift. For a story about the soap, click here. All the nurses use the exact same pattern of systematic hand washing when they stand there, which ends by cupping water in the hands to splash over the faucet, almost as if for good luck.

in an open ward, there are few sinks. this is one solution - a rolling wash stand. the alternative is to not wash your hands between patients..... eeeewwwww

in an open ward, there are few sinks. this is one solution – a rolling wash stand. the alternative is to not wash your hands between patients….. eeeewwwww

Different generations of hospital construction

Some hospitals are old but many new ones were built in the past five years

On a medical-surgical ward, you still get the open-ward design ala Florence Nightingale.

On a medical-surgical ward, you still get the open-ward design ala Florence Nightingale.

Personal hygiene needs of patients

At night, a family member brings in a bed roll and sleeps under the bed, awakening at two in the morning to measure and record their relatives’ intake and output. If a patient is incontinent, the linen is changed by the family. At seven in the morning, the Chowkidars come and sweep through the wards, telling the relatives that they must leave for the two-hour period of doctors’ and nurses’ rounds. So as the employees arrive through the front gate, they are met by a stream of tired people carrying bedrolls.

Brad Wong photo, 2008. women's inpatient ward. eleven women, one bathroom.

Brad Wong photo, 2008. women’s inpatient ward. eleven women, one bathroom.

Water sanitation

Each unit has a Eurogard water purifier mounted on the wall, which plays a twinkly tune when water is flowing through it. There is only one water pitcher which is shared by all the staff, refilled from the Eurogard.

refilling the shared water pitcher from the Eurogard water purification device.

refilling the shared water pitcher from the Eurogard water purification device.

There are no paper cups. All the Nepalis are experts at drinking straight from the pitcher without actually touching their lips to it. If a person’s lips touch the pitcher, that breaks the rules of caste. The first ten times I tried this I spilled water over my scrub shirt.

Khana Khan6

Brahmins will only eat food prepared by other Brahmins. In the hospital neighborhood, there are more than dozen small hotels and each has a kitchen. These hotels cater to the families of patients, since many come great distances to get to Mission Hospital. The family will stay in a nearby hotel appropriate to their caste, and rely on the hotel staff to make dal-bhaat. At ten o’clock in the morning and again at six pm, there is a parade of families bringing dal-bhaat on covered stainless steel plates.

The hospital does not provide food for the adult patients, unless they need a supplement, in which case they get Sarbotham Pitto. This is mainly grains with some vitamins added, and the staff would cook some over an open gas flame every morning. The smell of porridge now makes me think of mornings at the hospital, a sort of olfactory hallucination.

There is a Hotel-Wallah at each hotel. These men accompany the family members to the hospital and sometimes help the chaplains or the doctors with various tasks. The hotel neighborhood was given the name Shantytown many years ago, but then the Nepalis adapted the same name, because Shanti means peace in Nepali.

Intravenous medication prep

The usual time to give daily medications is one PM. The doctors write the name of the medication directly on the medication administration record and the nurses do not recopy the medication list. This is considerably simpler than the system most American hospitals use. Mission Hospital does not have a pharmacist in the Pharmacy department. The medical staff only uses five antibiotics most of the time – gentamycin, ampicillin, penicillin, chloroamphenicol, and cefazolin. For adults, there is a standard dose for each one except the gentamycin. The nurse counts up the number of doses of ampicillin and reconstitutes them all at once, then does the same for the next antibiotic. The doses are piled on a single tray with one divider for each medication, not divided according to patient or room number.

In USA we stopped using chloramphenicol years ago due to the slight but unacceptable risk of aplastic anemia. It's a very effective antibiotic; still in use in Nepal

In USA we stopped using chloramphenicol years ago due to the slight but unacceptable risk of aplastic anemia. It’s a very effective antibiotic; still in use in Nepal

There are no trips back and forth to the medication preparation area once the nurse starts medication administration rounds. A checklist is used to indicate who gets what, but the individual syringes are not labeled with the drug name or individual names of patients.

UPDATE: more of the big  city hospitals are using unit-dose these days. There is always a pharmacy on the premises of a hospital – the family has to buy the meds, with cash as a rule.

unit dose, at the bedside, in one of the newer hospitals. Most of the hospitals in Kathmandu were intact after the earthquake. Yes, there were overflow patients outside.

unit dose, at the bedside, in one of the newer hospitals. Most of the hospitals in Kathmandu were intact after the earthquake. Yes, there were overflow patients outside.

Intravenous administration

The stuff on the IV tray is not what you are used to, and the actual holding of the IV needle when you are inserting, is different.

They use a certain kind of cloth tape that is bombproof - it never comes undone. sometimes you need it......

They use a certain kind of cloth tape that is bombproof – it never comes undone. sometimes you need it……

Most medications are given IV push. In the US, many antibiotics are given using a “piggyback” bag, but this system is less often used at Mission Hospital. There are no IV pumps; everything is dripped and the drop rate is controlled by a hand roller on the IV line, the old fashioned way. (note: as of 2015, more hospitals are using a “syringe pump’- what we used to call a Harvard Pump, back in the day)

A syringe pump. In USA these days, pretty much every IV is on an infusion pump. Nepal hospitals generally free-hand the IVs. This one is being used for dopamine.

A syringe pump. In USA these days, pretty much every IV is on an infusion pump. Nepal hospitals generally free-hand the IVs. This one is being used for dopamine.

Even dopamine, which is a powerful adrenergic drug, is given this way, with the added precaution of a “burette.” As a rule, the patients have excellent veins – few people are obese. Many are manual laborers. It is easy to start an IV on a Nepali. No central lines and no PICC lines. The hospital does not yet have a needleless system.

The system for disposing of biomedical waste is not always what you wished it would be. SOme things are recycled - for example, med vials do doubleduty as specimen containers - but, not everything.

The system for disposing of biomedical waste is not always what you wished it would be. SOme things are recycled – for example, med vials do doubleduty as specimen containers – but, not everything.

The nurses do not routinely wear gloves when handling IVs.

DRESSINGS

A nursing student preparing a dressing tray.

A nursing student preparing a dressing tray.

There are no wound vacs. There is a minimum of disposable supplies. sponges are not individually packaged. the kits are wrapped in cloth. The nurse uses two implements, not their gloved hands

Chest Tubes

I rarely saw three-bottle chest drainage while I was there, and when it was needed they literally used three bottles on a little wheeled stand – no pleurevacs.

Mostly they stuck to one drainage bag – strictly speaking, the “second bottle” of the three-bottle system. The first time I saw this I was skeptical. Surprisingly this system seems to meet most of the need for chest drainage.

transfer from bed to stretcher

The wooden beds are not adjustable. The beds are too close together to permit a stretcher in between, so when a patient needs to move from bed to stretcher the family does it or else we call the peons to come in a group of three and do a manual transfer. Sometimes relatives cry as they watch this. It was not until later that I learned the reason. When a person’s body is cremated, three male relatives will lift it onto the pyre the exact same way. It triggers a memory. Women never attend a cremation in Tansen, by the way. Only men. By the same token, men never attend childbirth, not even if they are the father of the baby being born.

Linen service

Nobody will get into bed between two white sheets, not for a million rupees. The sheets are blue or pink. White is the color of a shroud. There is space on the roof for clotheslines, and on sunny days baskets of wet sheets are carried up three flights of stairs and set out with clothespins.

DSC02681

The hospital owns an industrial clothes dryer but only uses it during monsoon, to save electricity. The mattresses are about two inches thick, just like the ones at a typical Nepali home. Many people do not sleep on a mattress at home, just a woven mat.

Childbirth

you might want to brush up on how to use this.

you might want to brush up on how to use this.

The vast majority of newborn deliveries in our district take place at home. If the mother develops postpartum complications she is admitted to the Gynae Ward, not to the Maternity Ward. The Gynae Ward is an eleven-bed all-female “Nightingale style” open ward with drapes between. Babies are not given a name until eleven days of age. So the census lists them as “b/o Sanjita” or some such. b/o is short for “baby of…”

The Nepal government decided to pay for childbirth in hospital, which is a good thing. here is the list of benefit.

The Nepal government decided to pay for childbirth in hospital, which is a good thing. here is the list of benefit.

as above. the same list in Nepali

as above. the same list in Nepali

on OBS Ward. emergency drugs used for PIH cases. The systems may not be fancy. they are limited by lack of money. But that does not mean that nobody has thought them through.  On the contrary, somewhere along the way they given planned things out.

on OBS Ward. emergency drugs used for PIH cases. The systems may not be fancy. they are limited by lack of money. But that does not mean that nobody has thought them through. On the contrary, somewhere along the way they given planned things out.

Nepal uses the Bikram Sambat calendar. here is one handy-dandy way to determine EDC in Nepal. Got it?

Nepal uses the Bikram Sambat calendar. here is one handy-dandy way to determine EDC in Nepal. Got it?

meconium aspirators are usually made of see-through plastic, and disposable. this hospital hired a local metal fabricator to make some that could be sterilized and re-used.

meconium aspirators are usually made of see-through plastic, and disposable. this hospital hired a local metal fabricator to make some that could be sterilized and re-used.

Scrap paper?

It is hard to find a piece of scrap paper. The charts include just the most important information. The hospital keeps the standard forms to a minimum, printed on cheap paper.

If the patient is illiterate and needs to witness consent for an operation, there is an ink pad available so that a fingerprint can be used instead of a signature. When a patient is discharged, they are given their chart.

The medical record department of a 400-bed hospital. Most patients are given their chart when discharged. They don't have CPOE yet.

The medical record department of a 400-bed hospital. Most patients are given their chart when discharged. They don’t have CPOE yet.

Payment for services

To get seen by a doctor in the ER or Outpatient Clinic, somebody has to go to the ticket window and buy a ticket. It must be paid for in cash before the doctor visit.

waaay before the morning rush. Every hospital has a ticket counter.

waaay before the morning rush. Every hospital has a ticket counter.

There is a huge outpatient waiting room with long wooden benches. Downstairs from the main floor are separate clinics for leprosy, TB, and HIV disease, but there are many undiagnosed TB cases among the people sitting in the waiting area.

Functional Nursing

The Nursing Department of the Hospital is organized using a “functional nursing” model. Nursing report is in a mix of English and Nepali. Each employee starts the day with an assigned list of repetitive tasks. In other words, there is one nurse who gives all the medications, one nurse who takes all the blood pressures, one nurse who changes all the dressings. The only nurse who really has the Big Picture is the Charge Nurse or, didi. If you asked a staff nurse how they know when they are doing a better job, they would probably reply, “Because I can get the medications delivered more efficiently.” This is in contrast to other models of care delivery that might be more conducive to an outcomes-oriented approach, where the nurse might reply, “Because my patients are improving faster with fewer complications.”

Nursing School

The Nursing School is located just downhill from the Hospital, connected by a long straight stone staircase. The school is brick, constructed like a military fort with classrooms, offices and dorm space around a central plaza, guarded by its own Chowkidars. The students stay five-to-a-room, and the dorm rooms are smaller than my faculty office at the University. A student once told me that most of her classmates kept the same roommates for the entire three years of school. Restrooms and showers are at the end of the hall. The School has its own canteen, and if a student was on night duty she is allowed to appear in a track suit or something casual.

Locavores

When I ate at the canteen I enjoyed looking through the window to see the dozen or so goats owned by the School. The kitchen staff each take a turn at watching the goats, and every now and again a goat ends up in the mutton curry. As the main ingredient.

Nurses Uniforms

Students wear a uniform and old-fashioned nursing cap when at Clinical; on class days a bright purple sari with a white top, hair pulled back and no skin showing at the midriff. When the students cross the courtyard in their saris, it is like a flock of blue-and-white penguins going by.

The school uniform worn for classroom and community health nursing experiences.

The school uniform worn for classroom and community health nursing experiences.

There are no male students. On Saturdays students are allowed to go the Bajar in western-style clothes.

Mobile Phones

They are not allowed to have cell phones, a great hardship for teenage girls nowadays.

Census Book

In the census book on the patient care floors, a column lists the caste of each person admitted. Nurses are very good at guessing caste without asking. At first I wondered why there were so many people with the last name “ Bdr.” Bdr is short for Bahadur, meaning that the patient is a Chhetri. Chhetris are the warrior caste, and Bahadur means “brave.”

If you got this far

If you got this far, you deserve my thanks. I’ll keep tweaking this in coming days. Also, the first book and this excerpt, focused on the physical aspects of the setting for health care. My second book, The Sacrament of the Goddess, focused more on the culture(s) of Nepal, and how this influences the way that decisions are made. It’s more about the interpersonal aspects of culture.

Required reading for every medical person who thinks he understands what goes on in Nepal...... available on Amazon at  http://www.amazon.com/dp/1632100029

Required reading for every medical person who thinks he understands what goes on in Nepal…… available on Amazon at
http://www.amazon.com/dp/1632100029

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Grief in Nepal, a short introduction post-earthquake, May 6th 2015


From The New York Times May 5th 2015. This scene is not new to nurse or doctor in Nepal. Tourists normally do not see this side of Nepal. http://www.nytimes.com/2015/05/06/world/asia/high-in-the-himalayas-a-search-after-the-nepal-quake-yields-grim-results.html

From The New York Times May 5th 2015. This scene is not new to nurse or doctor in Nepal. Tourists normally do not see this side of Nepal. http://www.nytimes.com/2015/05/06/world/asia/high-in-the-himalayas-a-search-after-the-nepal-quake-yields-grim-results.html

We are eleven days post-earthquake as of today.

May 7th update: for three years prior to the earthquake, I have dealt with culturally-specific reactions of Nepali people to unexpected tragedy and loss. For any person or group that deals with this issue, please read this previous blog entry. then feel free to contact me. The problem of anger is only going to get worse, in my opinion.

A Nepali friend who is wonderful and compassionate and young, wrote on her FaceBook page:

what do u say to a person who denies to stand from the bed..because he doesnt want to live anymore..because he lost his son,daughter,grandchildren, house everything all in a day..what do u say to him? with what words do i console him? I am feeling emotionally drained…..

In the New York Times see the picture above. Yes, there is a woman there in the center, in the deepest pain a person can feel.  I don’t cry easily but I did. And yet – there are eight other women right there. these are her “cousin-sisters” perhaps, or her “sangha” and they exemplify the deep collectivism of Nepali culture. She is grieving and those women are there for her.

“They’re going to need grief counseling here,” is the conventional wisdom.

You would think I would glibly find a way to lead you into this blog. But – I cannot. I told my friend: “Allow yourself to cry.”

And this was for a Nepali person. I am assuming that western counselors will come here and offer advice.

For the nurses and doctors:

I teach critical care skills to nurses and doctors here in Nepal and have done so since 2011. I teach many high-tech skills for resuscitation of people when their heart has stopped. It’s the core of what I do. But from the beginning I have been reminded by my Nepali colleagues that the best-delivered team response in an emergency does not always save the victim. (something I already knew long ago in USA). Not only that, but there are cultural manifestations of acute grief here, that must be addressed at the time of death. For that reason, I always budget time in each class session to role play the scenario of counseling the “patient party.” In each of the sixty five sessions I have led, we engage in an open-ended problem-solving discussion as to how to proceed when we did not save the life of the patient. Participants share stories. We debrief.

Every Nepali nurse and doctor has needed to deal with counseling of family members in deep shock who express their grief by acting out. This is a “collectivist” society, with specific implications regarding the way the group reacts to a bad situation.

Clarification: click here to another earlier blog entry about specific manifestations of acute grief in Nepali hospitals that was a nationwide problem, before the earthquake.

If you are a western mental health specialist who is thinking of coming here, be advised that you really need to study the material on Hindu and Buddhist rituals of grief and mourning before you come. One of the true strengths of Nepali society is the way that it supports individual members who are in grief.

Here is an intro on mourning in Hindu culture. This one is particularly important because it describes Pashupattinath, in Kathmandu.

Here is another excellent one. And another, this one by a western woman married to a Newari guy. And another that describes Buddhist rituals.

Post-traumatic Stress Disorder

In my second book, The Sacrament of the Goddess, I was going to write about how one particular character picks up the pieces of her life after a traumatic event. Then I realized, everyone in this book is picking up the pieces after a traumatic event.  And I developed each character as the book unfolded, with that understanding.

For these reasons, I guess you could say that I have studied this issue of acute grief in Nepal for three years. The most important thing to tell all my Nepali friends? Start by allowing yourself and your friends, to simply be human.

Start by allowing yourself to weep, if that is how you feel. We will all be here for each other.

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Florence Nightingale’s birthday in #Nepal after the quake, May 4th 2015


Florence Nightingale created the modern nursing profession as we know it today. Happy Birthday!

Florence Nightingale created the modern nursing profession as we know it today. Happy Birthday!

International Nurse’s Day is May 12th, celebrating the birthday of Florence Nightingale. Florence Nightingale is revered in South Asia, though she never travelled there. It is attributed to a report she wrote for the British Raj, reforming the public health system of India, over the course of forty years of her life.

You will still see pictures of Florence Nightingale in hospitals in Nepal, usually in the Matron’s Office. Here’s the one from Crimson Hospital, in Manigram, Rupandehi district.

Nepal is in mourning, and will be for one year according to Hindu custom. Today's was International Nurse's Day, and I was honored to share it with nurses and others at Crimson Hospital. The ceremony was simple - sort of a "Florence Nightingale puja" - candles lit. Main thing was a minute of silence to honor those who were killed April 25th.   They asked me if I would help distribute a small gift of fruit to every patient. While we making the rounds, an after shock. Everyone ran outside. The TV news said it was a 6.9 in Kathmandu

Nepal is in mourning, and will be for one year according to Hindu custom. Today’s was International Nurse’s Day, and I was honored to share it with nurses and others at Crimson Hospital. The ceremony was simple – sort of a “Florence Nightingale puja” – candles lit. Main thing was a minute of silence to honor those who were killed April 25th.
They asked me if I would help distribute a small gift of fruit to every patient. While we making the rounds, an after shock. Everyone ran outside. The TV news said it was a 6.9 in Kathmandu

Every nurse in Kathmandu was walking in the footsteps of Florence Nightingale right after the quake.

Nurses needed in Nepal?

Since the earthquake, there is a lot more interest in the health system of Nepal – nurses and doctors from western countries are interested to volunteer for earthquake recovery. Here is the best advice about volunteering. In this early period, some specialized skills are needed, but don’t come without a sponsoring organization. Be advised, there are ample nurses and doctors within the country to meet their own needs for personnel. If you have never done international nursing, Nepal is not an easy “first Asian country.”  feel free to send email to joeniemczura@gmail.com to get advice on how to prepare for serving in this country.

Hundreds of nurses from Kathmandu took training from CCNEPal in critical care skills, since 2011

Hundreds of nurses from Kathmandu took training from CCNEPal in critical care skills, since 2011

Hundreds of nurses from Kathmandu took training from CCNEPal in critical care skills, since 2011. Here are some from Global Hospital.

Hundreds of nurses from Kathmandu took training from CCNEPal in critical care skills, since 2011. Here are some from Global Hospital.

If you do come to Nepal, here is something you can donate to nurses that will be incredibly useful, and is “sustainable.”

Some facts about nursing in Nepal:

Nurses in Nepal performed heroically during the recent earthquake, especially in Kathmandu. Normally nurses never get media coverage, but this has changed. Let’s hope that a new level of media coverage of nursing issues will emerge from this tragedy.

Nursing school in Nepal

Young women can go to nursing school at the age of sixteen, enrolling in a PCL program (Proficiency Certificate Level) for three years.

An in-depth description of Nepal Nursing Education can be found here.

There is one doctoral program for nursing, located at Institute of Medicine in Maharajganj, a neighborhood of Kathmandu. There are M Sc programs, but until recently most nursing leaders studied abroad for their graduate degree.

There is a “Nepal Nursing Council” and they are members of the International Council of Nurses. The Council has valiantly upheld standards for nursing education despite a politically unstable government.

Most often, nursing students live in a hostel at the hospital that sponsors the school. These hostels enforce strict rules such as no cell phones, no appearing in public unless in uniform, and the like.  The students  often live five-to-a-room with the same girls for three years, and develop lifetime bonds. There is nothing like sharing a bar  Cadbury’s chocolate between friends.

(photo by Brad Wong) morning rounds in a Nepal hospital.

(photo by Brad Wong) morning rounds in a Nepal hospital.

The school uniform is sometimes a Kurtha Suruwal (“Punjabi”) but often a colorful saree. Nursing students still wear a cap at many schools.

The school uniform worn for classroom and community health nursing experiences.

The school uniform worn for classroom and community health nursing experiences.

Every PCL nurse is also a midwife. The curriculum involves delivering a dozen babies under the supervision of an older nurse. The nursing students live in a society with strict gender rules. Though they have delivered babies, it is often the case that they themselves have not been on a “date” or had a boyfriend in the traditional sense that an American would define.

The PCL nursing curriculum is centralized and standardized by a government agency.

In the past five years, more young women are enrolling in “B. Sc.” nursing programs.

B. Sc. students with their Faculty member. Bhairawaha Nepal May 2014.

B. Sc. students with their Faculty member. Bhairawaha Nepal May 2014.

Males are not allowed to enroll in nursing school. They go to Health Assistant program instead.

Nursing as a career in Nepal

Traditionally, nursing as a career choice was frowned upon by upper caste Nepalis, because it involved contact with body fluids of other castes. This has begun to change since nurses have gone abroad, earned money outside the home, and sent remittance back to Nepal. Also, investing in the young woman’s education will bring a better choice when the time comes for arranged marriage, which is still widely practiced in Nepal.

There is an active “brain drain” of experienced nurses from Nepal to western countries such as U.K., Australia and India.  For a discussion of factors related to this, click here.

Nepali nurses abroad

Many Nepali women are going abroad for nursing education in USA or India but they face obstacles when they return. A person with a “foreign” (American) RN license is required to take the Nepali version of NCLEX to get a Nepali RN license, even if they are a Nepali citizen.

In Kathmandu, forty per cent of passed-out nurses are unemployed or working as unpaid “volunteers.” B Sc prepared nurses are viewed as lacking in skills and too outspoken.

There is a Nepalese American Nurses Association named NANA, based in Queens New York.

The model of care most widely practiced in Nepal is “Functional nursing,” in which assignments are divided by task.

Specialty nursing, (such as ICU nursing)  is in it’s infancy in Nepal. Such things as ecg analysis or principles of Advanced Cardiac Life Support are not widely taught to nurses.  Many nurses work  for international Non-Governmental Organizations (NGOs) on public health projects.

The author of this blog has written two books on health care in Nepal, The Hospital at the End of the World and The Sacrament of the Goddess.  Each has been described as “required reading for any nurse of doctor planning to volunteer their services in Nepal.”

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