The Siren Song of Global Health electives in Nepal July 2016


The siren song of Global Health in Nepal

this is for my USA readers. Most of the time I comment on events here in Nepal it’s directed to a Nepali audience. Not this time.

In USA these days the wish to include a Global Health experience into education is stronger than ever. For medicine, nursing, public health, and other specialties, the college or University graduate programs are testing the waters for clinical placements of various kinds. Nepal has always been an adventuresome choice for brave souls, and Nepal has a mystique about it that beckons.

Expanding the menu

The vast majority of North Americans go to just one or two locales in Nepal for an elective, and these are getting crowded. The magic gets diluted when it becomes a stop on the international trail. For example, one of the more popular places is now hosting up to a hundred foreigners at any given time. This changes the nature of the experience. A related question is “With twenty medical colleges in Nepal, why is it that only two or three become the hosts of the foreigners?”

Serving as a resource

At the spring 2016 meeting of the Consortium of Universities for Global Health, I met many people who asked if I’d share contact information at all the places I go, and give advice as to what medical services were offered. So I plan to compile a sort of offbeat guidebook to the  hospitals and schools with which I interface.

I’ll include photos, a description of the geographical location, pics of the buildings, and contact information of key people at each place.

Travel agency?

Um, no. I’m not a booking agency. I think there are many different levels in which a professional person can participate in global health. My audience for this would be people with bonafide credentials that wish to gain perspective. This is not ” trekking with toothbrushes”nor is it volunteering at an orphanage or teaching English to Tibetan exiles. Those are worthwhile for some people, but not related to what I do when I am here.

So be on the lookout. If you have questions, send me an email.

 

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July 21st report for the summer and upcoming schedule


I’m back in Bharatpur, where I was a month ago. The return bus ride through eastern Terai was wonderful – like riding through The Shire.

Statistics to date:

As of today I taught 19 sessions, with 560 certificates awarded.  The present plan is to teach five more sessions, with possibly 150 more certificates – if that works out it will mean I trained 710 nurses, doctors and others, this summer. On the FB page, I made a photo album that consists of one group picture for each batch.

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It is a large number of people, and the goal has been to introduce the idea of ACLS as widely as possible.

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The schedule?

July 24th, 25th, and 26th – Chitwan Medical College staff nurses.

July 27th, 28th and 29th – Chitwan Medical College B Sc Nursing students

July 30th – travel to Kathmandu via bus. should be the final bus trip of summer 2016. Hooray!

July 31st, Aug 1st Aug 2nd – BN students at a school of nursing in Kathmandu.

August 3rd, 4th, 5th – Norvic Hospital, Thapathali

August 6th, 7th and 8th – possibly a hospital in southern Kathmandu Valley.

August 11th – return to USA.

It’s been a productive summer and I have brought the info to new places. I previously taught 2,170 people, the grand total will now bump up to 2,880 if the plan holds up. Many thanks to all who made it possible.

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Ten Rules to Prevent Thrashing of Doctors in Nepal


When a patient dies, the doctor is often blamed, and the family is angry. Thrashing the doctor is is a problem throughout Nepal. I made this list for my most recent sessions of Critical Care Class. The reality is, we are all going to die, and when we do, there is nobody to “blame.” It is not the doctors fault.
Communication is the key
Effective resuscitation more than just the ecg, BLS and drug protocols. The leader of the team must manage the interactions with patient party, and also with administration and police if things do not go well.
The Leader of the resuscitation team must recognize that the team is not just the other doctors and nurses, but also the guards and sometimes the police. It is not enough to only focus on resuscitation. Also, in previous blogs I have given link to checklist for secure building.
1) Goals The goals of resuscitation are always:

a) conduct the most effective resuscitation effort possible,

b) allow family to express emotion, ‎and

c) keep all parties safe from harm.

2) Weapons if any patient party shows a weapon, run away. You are never being asked to sacrifice your own life for doing this work.
3) Access limit access to emergency room or ICU asap when critical ‎situation develops. All exits and entrances must be guarded or secured.
4) Security Guards communicate with chowkid‎ars. This is two-way. Chowkidars serve as eyes and ears beyo‎nd the ER door. If patient party outside is upset, they alert staff. If staff is having problem, guards are notified. If problem develops, chowkidar sends for extra help. If ER doctor directs doors to be shut, immediate limitation of traffic must take place.
 
5) Police pre-enter phone numbers of administrators and prahari into all smart phones. If a situation gets out of hand you do not want to be looking up the number. For that matter, invite the local police to the ER on a quiet day so you will know each other.
6‎) Counseling send staff person to sit with anxious relatives. Staff person assesses education level and directs teaching to most educated person present. 
7) Chairs give patient party opportunity to sit. (‎more difficult to get physical).

8) period of respect after death if death occurs, ALWAYS wait fifteen minutes before allowing family to view the body so that remains will no longer be “twitching” – this is very upsetting and confusing to many persons.

9) mutual support doctor brings a nurse and chowkidars when counseling patient party.

10) Tone of voice pay strict attention to tone of voice of staff at all times. Apply principles of “de-escalation” whenever tone starts to escalate.

This blog has given ample advice on this subject, browse past entries to learn more.

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June 6th update as to schedule


Update
CCNEPal has completed the sessions in Pokhara.
I loved meeting all the people there. Dr. Umid Shrestha of Paschimanchal Community Hospital and Matron Sushila Neupane of Charak Memorial Hospital were wonderful hosts. ‎ I thank them. They are visionaries for the future of critical care in Pokhara.
I gained much appreciation for the level of skill to be found among the interns and medical officers from Manipal College of Medicine.
I think the ICU at Charak Hospital is every bit as well-organized as any ICU in the Kathmandu Valley. An ICU is measured by the skill of the nurses, not by the equipment list.
Students in the nursing sessions came from PCH; Fishtail Hospital; Fewa City Hospital; Western Regional Hospital; and  Gandaki Medical College as well as from Baglung, Damauli, and Gorkha.  I was joined for one session by Tina Byrnes, RN from Sydney who is conducting a nursing project in Kirtipur under the aegis of PHECT, an Ozzie quasi-governmental entity.  I think I gave her a few ideas.
I did not previously know there was a “New Road” in Pokhara. ‎
Bharatpur, College of Medical Sciences
June 4th was a bus trip to Bharatpur for the next leg of the journey. I’m trying to minimize bus travel.
I got to the tourist bus station okay and used the toilet there. Normally I wouldn’t add such a detail, but the electricity was off and the toilet was pitch black dark. Not even one photon. Ever try to use an unfamiliar bathroom in the dark? I didn’t want to use my smartphone flashlight for fear of dropping it in ” the hole”.   In the process of getting my trousers back up, my wallet slipped from my pants pocket. I ran back for it when I noticed it missing, almost left it behind. I do a lot of “check twice, you’re not coming back here again” when I travel, glad to have developed the habit of patting myself down.‎
From Pokhara to Mugling the road travels through a scenic region that evokes “The Shire.” Looking out the bus window was a travelog of village life in the hills – verdant fields, people tending to tasks of daily life. The road between Mugling and Narayangarh was a mess, due to a widening project. Many stretches of one-lane road. The drivers were patient with each other. ‎ It will be great when it’s done. Just not now. The Nepali method of road widening seems to always start with demolishing the previous road. ‎ This is the road that hangs on the steep side of  a river gorge. There are places where it seems like the engineers just flung it up there to see if it would stick.
 We’ll have three sessions of the course here at CMS.
June 5, 6, 7 – 4th-year B Sc nursing students. (thirty)
June 8, 9,  – MBBS/interns. (twenty)
June 12, 13, 14 – 3rd-year B Sc nursing‎ students. (thirty)
My contact person here is Mrs. Sita Parajuli, Matron of the Hospital and Campus Chief.  Sita Ma’am was in Tansen for many years, so even before I met her here in 2011 we shared many mutual friends.  Sita Ma’am has advanced nursing in the Terai. Due to the education system here, CMS faces turnover among the nursing staff. Young PCL graduates stay two years then go for their BN degree (this system is being changed because of this very problem). Sita is always growing the leaders and the staff.
June 15th, 16th and 17th are open dates. I’ve been asked to work with one of the small hospitals here, this is not confirmed.  If I do, I’ll post it for possible students to join, who may be otherwise unafilliated.
Janakpur?
June 18th I leave for Janakpur, home to the famous temple. I am told they are starting up an ICU in that city. The time is just flying by.
Kathmandu?
I’ve gotten inquiries about Kathmandu sessions. There are none planned. I’ve spent ample time in Kathmandu in the past. About 800 nurses and doctors there got my training.  Sure, there is demand for more, but Kathmandu has many people who could be teaching this.
A comment about mission of CCNEPal
CCNEPal’s goal is to promote critical care skills using a training method exemplified by the BLS and ACLS courses of the American Heart Association (AHA) in USA. We are emphatically *not* part of AHA, and this course does *not* lead to AHA certification. Due to AHA’s impeccable and authoritative  scientific research about resuscitation, we do teach the AHA standard when we can – adapted to the needs of Nepal. Participants learn in Nepali language. You do not need to be expert English speaker to benefit from this training.
It has been obvious from the beginning that we need to teach “what ACLS is” before we can teach how to do it. That is why we offer our sessions to the largest number of nurses and doctors possible. We are trying to create a medical culture shift that recognizes ‎the need for trained nurses in critical care.
What is “sustainable?”
A couple of years ago, I met a USA doctor from a famous USA medical center who told me what I was doing was “not sustainable.” In the meantime, that same doctor trained about a dozen people in her sub-specialty. ‎ It will be ten years before the training she did will come into general knowledge. That was a drop in the bucket considering that Nepal has thirty million people. By comparison, CCNEPal has trained 2,300 as of this year, and many of them used their new skills on April 25th, 2015. The nurses and doctors who need this knowledge are the young ones at the beginning of their careers, now working directly with patients. Persons who come to Nepal to train need to find a way to reach a broad audience, and not limit it to the senior doctors doing mainly administrative work.  “Train the trainer” is more difficult to do and implement that some might think.  I ten words or less: what I do is more “sustainable” than what that other person was doing.
If you are a foreign medical personnel thinking of coming here to train, you are invite to browse this blog.
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The Overall Schedule for CCNEPal summer 2016 is taking shape


The Theme of Summer 2016

In past years, I don’t worry too much about what the schedule will be when I get to Nepal. As long as the first few days are scheduled, I know I will get many eager requests to go here or there. The only small city on the 2016 list is Jumla.

infographic of medical education in Nepal 5

Half the population of Nepal lives in Terai. All the medical schools in Terai are non-governmental, i.e., “private” – and I should add, in this region of Nepal there is a higher per centage of Hindi speakers.

Generally, the eleven weeks this time will be divided into two week blocks. As of today, the first eight weeks are spoken for, and I’ll confirm weeks nine & ten soon.  The work week in Nepal is six days. I take Saturday off each week. Less travel time = more teaching time.

I plan to post a photo album for each session, on the CCNEPal FaceBook page.

Pokhara ( 1 & 2)

2-day session for MBBS docs and interns May 19th -20th

3-day class for nurses May 22nd, 23rd and 24th; then

another 3-day class for nurses on May 25th, 26th and 27th;

then 2-day course for MBBS, May 29th and 30th;

then 2-day class for MBBS, May 31st and June 1st;

About the town: Pokhara is neck and neck with Biratnagar for the title of Nepal’s second-largest city, with about 353,000 people. It is the jumping off point for many treks, and is situated on one of Nepal’s few lakes. I have taught there twice before, for a total of a hundred nurses. There are two medical colleges in Pokhara. The host is Paschimanchal Community Hospital, Buspark, Prithvichowk, Pokhara. The contact persons are: Dr Umid Shrestha, and Sushila Neupane who now is at Charak Memorial Hospital.  (please note that is a correction- I originally gave the incorrect hospital). I will be staying in the city, above and away from “lakeside” while there.

Pokhara_Montage_2

On June 2nd, CCNEPal will travel to the next location.

Bharatpur (3 & 4) – College of Medical Sciences  (CMS)

teaching a 3-day class to nurses and/or nursing students on
Sunday-Monday-Tues June 5th,6th and 7th.
then a 2-day session for MBBS June 9th and 10th;
Then another 3-day class for nurses June 12th, 13th and 14th;
and finally a 2-day session for MBBS/interns June 16th and 17th.

About Bharatpur. This city is located where the road from Kathmandu intersects the east-west highway across the Terai. I first taught here in 2011. The city has two medical colleges, the old (“Purano,” also known as CMS) and the new (“Naiyyan,” also known as CMC). I did not know their official names for quite some time.  CMS has several distinctions. First, they have the single busiest Emergency Room in Nepal, with a breathtaking level of activity. Next, they serve a population that comes down from Makwanpur, the nearby hill district. Bharatpur is the city closest to Chitwan National Park. Contact person there is Mrs. Sita Parajuli, Matron of CMS Teaching Hospital. Also, Dr Biswas Gurung will know where to find me.

Janakpur ( weeks 5 & 6)

2-day version of class for  MBBS, June 19th  and 20th (30 seats)
2-day version for MBBS June 21st and 22nd (30 seats)
2-day version for MBBS 23rd and 24th (30 seats)
3-day version for nurses, 26th, 27th and 28th (30 seats)
3-day version 29th, 30th and July 1st (30 seats)
I will leave Janakpur the morning of July 2nd.

About Janakpur.  I have not taught here before, but they too have a medical college. Janakpur is the site of the Janaki Mandir, a legendary pilgrimage site for Hindus dedicated to the Goddess Sita. Janakpur is also the site where they filmed this documentary about trains.  The primary local language here is Maithili, not Nepali or Hindi.

Biratnagar ( weeks 7 & 8)

2-day version for MBBS July 3rd and 4th (30 seats)
2-day version for MBBS July 5th and 6th (30 seats)
2-day version for MBBS July 7th and 8th (30 seats)
then 3-day version for nurses July 10,11th and 12th (30 seats)
then 3-day version for nurses July 13th, 14th and 15th (30 seats).

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I was in Biratnagar summer 2014. That time of year, women apply mehendi. These are nurses who took my class. I worked with “CNEplanet” and enjoyed my time there, despite an auto accident on the way. I returned in 2015.

About Biratnagar. I taught here in 2014 and 2015. It is in the eastern Terai, the largest “industrial city” of Nepal. There is a sizeable Muslim population – the Muezzins start up at about 0430 every day. In 2014 they were having a hepatitis E epidemic, and The New York Times featured Biratnagar in this news video. I believe that this is the city where Lonely Planet wrote: “…there is no reason for any western tourist to ever visit this place.”

So – despite the above statement, I can truly attest to how nice the people are in Biratnagar. They were really super. The host agency is Nobel Medical College with Dr. Bandana Paudel.

I don’t drink the water when I am there. My contact person is Mrs. Dipty Subba.

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This is not Dipty’s usual head gear.

Jumla (weeks 9 & 10)

specific dates TBA.

About Jumla. I have a long story about Jumla, but then again, I have long stories about each of these places. Jumla is home to Karnali Academy of Health Sciences (KAHS), in far-western Nepal. I will go there for two weeks, and most likely using the shuttle as opposed to flying. How exactly to rendezvous with the KAHS shuttle, will be one of the loose ends of the summer. It’s on the opposite end of the country from Biratnagar. Biratnagar is twelve hours from Kathmandu by bus, and Jumla is two days by bus or shuttle.

KAHS is new, and the teaching hospital there has 30 beds. They had a fire in one building this past winter,  after which patients were treated on pallets on the ground in open air for a few days. They wanted me to go there last year to upgrade skills of emergency and especially pre- and post-op nurses, but this was cancelled after the earthquake. Contact person is Dr. Mangal Rawal.  I met him when he was completing his orthopedic residency at Bir Hospital in Kathmandu.

KAHS Jumla nurses 2016

from the KAHS FaceBook Page. The teaching hospital is small and so is the nursing staff.

Jumla has had low rain and crop failure so far in 2016. There are predictions of famine in the district.

After Jumla I will go to Kathmandu. I’ve been asked to do some teaching for an NGO that specializes in “health camps” in the mountains, and other groups. I think by that time, I will need to simply “chill” and enjoy the city.

The above plan is subject to change. It will minimize the bus travel. My 2015 bus accident took three weeks to recover from. Since then I want to avoid the out-and-back trips, designing a circuit instead.

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I travel light. Here is my collection of “props” for the class.

I will bring my own supply of “organic coffee.” The locals drink tea here as a rule.

The person who met me at the airport in May 2007 is Mr. Ram Maharjun, manager of Shalom Guest House. He will always know where I happen to be. I will also register with the  US Embassy, as in the past.

The best way to follow me is to “like” the CCNEPal FaceBook page.

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How to register for critical care training sessions in Pokhara May 2016


UPDATED with more specific info Wednesday May 4th and 12th

ACLS training registration can be done at:
Registration desk Paschimanchal Community Hospital Buspark, Prithvichowk, Pokhara – 9, Kaski, Nepal. Phone no. 061 530722 Email: pchospital2071@gmail.com

Please share widely.

CNEPal will return to Nepal for ten weeks in summer 2016. We will be in a variety of cities, mostly outside the Kathmandu Valley. Our goal is to create a widespread knowledge of principles of resuscitation and emergency response, throughout Nepal. In the past we delivered 70 sessions of this course, training 2,170 nurses and doctors. Click here for a report: http://wp.me/p1pDBL-yy

We will begin the summer by offering five training sessions in Pokhara Nepal, starting in May.

Here is what one person said after taking the class: https://youtu.be/XqBjcYSzU_k

This course covers emergency response and is modeled after the USA “Advanced Cardiac Life Support” course. (It has been adapted to meet the needs of Nepali learners, and is not the official American course).

Here is an example of what you will learn to do when you take this course: https://youtu.be/8uQ9sYSP_vY

This course has been taught twice before in Pokhara, with the cooperation of Kaski Sewa Hospital. We gratefully acknowledge their support and help. pokhara sign for CCNepal.jpg

Two sessions will be for nurses and three will be for MBBS docs. The nursing sessions will be three days long, and a participant needs to attend all three days. The MBBS sessions are two days in length. Click here for the detailed outline of the two-day course: https://joeniemczura.wordpress.com/2015/02/05/schedule-for-2-day-course-in-advanced-life-support-for-mbbs-docs-feb-5th-2015/

How to Register

Class space is limited, and you must register in advance.

Register by going to Paschimanchal Community Hospital, Buspark, Prithvichowk, Pokhara. The contact person is Dr Umid Shrestha.

The sessions will be conducted in the Hall of Paschimanchal Community Hospital, Buspark, Prithvichowk, Pokhara.

Here is a video from one of the previous courses in Pokhara: https://youtu.be/zIdBjw4VBaU

In 2013, we did two sessions in Pokhara and trained 95 nurses. There were participants from many hospitals and schools of nursing throughout Pokhara. We hope to have a similar cross section of nurses. Please note: if you took the course before, you are invited to help lead the small groups this time around.

You must attend all days of the session to get the certificate.

UPDATE: Fooding will be included.

Certificate?

Yes, there will be a certificate. It will be beautiful.

This is what the certificate looked like in 2013:butwal acls jombies 2.jpg

There is a final exam and if you don’t pass the final, you get no certificate. 

Hold the date!

2-day session for MBBS docs and interns May 19th -20th

3-day class for nurses May 22nd, 23rd and 24th; then

another 3-day class for nurses on May 25th, 26th and 27th;

then 2-day course for MBBS, May 29th and 30th;

then 2-day class for MBBS, May 31st and June 1st;

On June 2nd, CCNEPal will travel to the next location. We will announce further locations and sessions as they are confirmed.

go to CCNEPal’s FaceBook page and “like” the page. https://www.facebook.com/2013KtmCriticalCareNursingCourse/

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CCNEPal planning for summer 2016


CCNEPal is an ongoing educational project since 2011. We have trained 2,170 nurses and doctors in Nepal to use a particular set of critical care skills.

May 1st Update

I bought my ticket and I arrive May 16th to TIA.  I expect to scurry around Kathmandu doing errands for a day or two then get on a bus outside the Valley. First stop I am hoping for is Pokhara for two weeks.

The Big Audacious Goal

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MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal’s future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

CCNEPal’s goal is to promote cardiac critical care training throughout the entire country of Nepal so that it is “owned” by every medical school  and a broad movement of nurses and doctors are comfortable with using and sharing these skills.

Please refer to the report of 2014-2015 activity of CCNEPal to learn my assessment of present capability. The conclusion? Kathmandu Valley has got some good things going, and the best return for the effort will be from work in the Terai.

infographic of medical education in Nepal 5

Half the population of Nepal lives in Terai. All the medical schools in Terai are non-governmental, i.e., “private” – and I should add, in this region of Nepal there is a higher per centage of Hindi speakers.

For those Nepalis thinking about taking the training? It’s easy to find a person who took it before….. ask them if it was worthwhile.

And if you are one of those persons who did take it before… tell your friends. Ask your employer to host the training. I don’t charge a fee, but when it’s outside KTM I do ask for fooding and lodging.

Also – If you took it before – please join me as one of my “assistants” – it’s more fun the second time around.

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In May of 2013, CCNEPal started routinely including an anatomy lab in the 3-day session for nurses, to make up for gaps in science preparation ( something I had done in USA for years). For this we obtain en bloc heart-lug assemblies of mutton from local fresh shops. Here’s a shot of the coronary arteries.

Train-the Trainer takes more than just two weeks

We are trying to develop Nepali nurses and doctors to teach these skills and use them in daily practice throughout Nepal, so that it will be “owned” by a wide cross-section of Nepalis. What we do goes beyond the usual “train the trainer” program. The leaders of this course need to be persons who are using the skills in daily practice, but also able to effectively debrief according to what just happened.  When we model these skills in class, the participants begin to use them to critique their skills in the clinical setting.

Read past blog entries to get the course objectives, outlines, etc.

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CCNEPal uses role play to teach nurses and doctors about situational awareness. These are the actors from the first session at Crimson Hospital in BTWL, May 2015

I will be returning to Nepal for summer 2016. I have not bought my ticket yet, but it will be roughly May 20th to August 10th. As in the past, I don’t schedule sessions of my courses until I get there. I am humbled at the positive word-of-mouth references people give to the training.

General plan

Jumla

I will spend a few weeks at Karnali Academy of Health Sciences in Jumla. This is to fulfill a promise I made to a person who is now passed; but – also a separate promise I made prior to the earthquake in 2015.

Terai

I plan to do a road trip through the Terai.

Bhairawaha,

Butwal,

Bharatpur (x2),

Birgunj,

Biratnagar.

Nepalganj

I will go to BPKIHS in Dharan; and LMC in Palpa. I wanna go to Janakpur. I will return to Pokhara as well.

Traveling to widely dispersed cities becomes “my other life.”  I have friends in all these cities – in some cases they know each other but mostly not – and, people in Kathmandu don’t necessarily know my friends elsewhere…… something amazing always happens on these road trips…. I just don’t know what it will be.

I know it will be hot.

Unlike all the previous places,  I know nobody in Janakpur.  Anybody out there able to introduce me to Janakpur?

Pokhara? why not! I was there twice before and trained about a hundred nurses.

And yes, somewhere on the way I will teach in Kathmandu.

How to schedule?

So if there are nursing schools, medical schools, or hospitals that wish to host me, please contact me and we will set up some dates. I am especially eager to go outside Kathmandu Valley and to areas I have not been before. send email to:  joeniemczura@gmail.com

Maybe this is finally the year I will take a trek……

PS – For those persons in USA – If you are an ACLS-I or PALS-I  and you want to help out in Nepal, please contact me. What I do is not part of the American Heart Association, but I know the folks who run the one-and-only AHA ITC in Kathmandu, and they would love to have you affiliate with them.

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