Are nurses and doctors needed for earthquake relief in #Nepal right now?


About humanitarian work in Nepal

I have kept a blog on my work in Nepal since 2011, describing my little volunteer project to train Nepali nurses (and now doctors) in Advanced Cardiac Life Support. I’ve also got a FaceBook page for CCNEPal and a youtube channel where you can find videos that show what the hospitals are like. I travel around the country when I am here but I’m mostly based in Kathmandu.  I’m presently on a Road Trip through “the Terai” – the hot, humid and flat section near the border with India. I’ve watched TV with sadness these past few days.

Out of the 1,775 people trained by CCNEPal, about 800 are in Kathmandu, and I’m sure they are using their skills to the max.

I note that my blog hits have gone through the roof, and many of the search engine terms have focused on my past appeals for nurses to volunteer with me, here. I’ve gotten some emails and messages asking about this as well. I’m sure that some of it is due to a longing on the part of the sender to do something, to actually take a hands-on approach to deal with something that is very disturbing, and which calls for action. That is laudable – you wouldn’t be a nurse unless you had the urge to help other suffering people!

Immediate needs?

In ten words or less: don’t come here on your own, don’t come without an International Non-Governmental Organization to back you up.

The fact is, now is not the time for an individual nurse or doctor  to come to Nepal, certainly not without a sending organization to back you up, and most definitely not without a lot of planning. The best advice is to get involved in fundraising and awareness, and to send money to a reputable organization such as the American-Nepal Medical Foundation.

At present, the need in the affected areas seems to be for Search and Rescue, and for earthmoving equipment for recovery. In Kathmandu itself, people are not trusting their buildings and sleeping in the street. As I write this it’s raining. In this early period, they need blankets, tents, food and clean water. The agencies that can supply this logistical stuff, on an industrial scale, will be the ones needed. Any other person will need so much assistance to navigate daily life, that they will probably get in the way. They are in danger of epidemic illness due to lack of clean water, close proximity to potential infected persons, and exposure to the elements.

“These best time to plant a tree is – twenty years ago.

The second-best time is – now.”

I hear that MSF is sending surgical teams, as are other large INGOs. Usually these groups have members that have done international disaster work before, and also can work with locals. I think that one rule learned from most acute-phase disasters is, the people on the ground at the time, need to do the heavy lifting. And they will.

Intermediate needs

In what ways is this situation like Haiti, and in what ways is it not like Haiti? I don’t know, because I never was in Haiti; but be advised, it takes two full days of travel just to get here from the USA, as opposed to a two-hour flight from Miami. In Haiti, the USA aid groups rotated many people in and out for just a week at a time, which would be highly unlikely here. The lead countries are likely to be India and Australia, each of which has longstanding ties to Nepal.

I have the impression that most hospitals in Kathmandu, esp the biggest ones (TUTH, Bir etc) are fully operational. They have plenty of nurses and doctors ( there are a half-dozen medical schools in greater Kathmandu). There is a sizeable population of Nepali nurses and doctors who live in other countries for economic reasons – these folks would be the best volunteers for immediate needs because they are already familiar with the system and they speak the language. There are other regions of Nepal that are relatively unaffected and if it became necessary, personnel from there could go to Kathmandu. I should note that no such call for Nepali personnel from unaffected regions has gone out.

The system of care in Nepal is very different than that of USA, and it takes a while to learn.

Longer term needs

There is a system of nursing and medical education here in Nepal, and CCNEPal has worked with nursing schools and medical schools to offer our program. Just because you would not be able to help right now does not mean that you should not help in the future.

If you have not travelled to a Low Income Country before, there is the very real problem of culture shock, and “reverse culture shock”. This was true even before the earthquake, and without a sending organization you would not get the psychological support to put it into perspective.

Global Nursing  the long run

This event leads to the question of how best to prepare nurses in USA for global humanitarian crises of this magnitude. Groups like Sigma Theta Tau have brought attention to the need, but I wonder about how this has translated into action.  Nepal has historically not been paired with the USA under the W.H. O. scheme of things, which has impacted funding of health-related projects from USA to here. I think it’s time to consider ways that USA and Nepal can collaborate on nursing education as well as medical education.

what to do right now?

Get involved in fund-raising efforts.

If you wish to learn more about the culture and the way hospitals work here, read past blog entries and buy one or both of my books. Neither of them is a best seller, but they were written with the intent of helping a nurse or doctor “get hip” about Nepal before volunteering here.

If you wish to become more global-nursing conscious, start with these twelve steps.

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The power of fear and rumor in #Nepal right now, April 26, 2015


Let me be clear: I am in Bhairawaha, not Kathmandu. I am hundreds of miles from the capital city. I normally teach critical care nursing in Kathmandu and spend about fifty per cent of my time outside the Kathmandu valley. I decided to make a six-week circuit trip to the locations outside the valley, because it’s more efficient. Ever since the bus accident I have been a bit skittish about bus travel, and to do a circuit trip means that overall, I am not on a bus as much as if I was going out-and-back, out-and-back all the time.

Things are fine in Bhairawaha. We felt the quake. I knew what it was immediately, since I had lived in San Francisco years ago. I also knew that Kathmandu was in big trouble.

we had some aftershocks here. The only inconvenience was that Cable TV was not available.

So, today the decision was, to continue teaching my class, the one I teach to nurses and doctors. There were seventeen MBBS docs who showed up more or less on time.  And off we went.

It was my usual class – lots of interactivity, lots of group work, students taking video of each other and critiquing.

Until lunch. I had just dismissed the class for lunch, and was alone in the classroom.

at 12:54 we had an aftershock, and this one was the most powerful since the original quake, here. The building shook and people screamed. I realized there was no place to run, I was too deep in the building to get to the outside. I went under a concrete doorframe and stood. The shaking  stopped.

The patients and “patient parties” in the orthopedic ward nearby, decided to pack up and move outside, under the awning in the parking lot. The ortho ward was now empty.

Twelve of the seventeen docs in the class returned at 1:30 PM, and we held a vote as to whether to continue for the day. I realized that their bodies were in the class but their minds were elsewhere. We adjourned until tomorrow.

Four told me they wanted to stay and specifically work in ecg. So, we stayed and I guided them through this subject. This section was rather pleasant and collegial.

A guy came at 2:50 to tell us that at 3 PM there would be an earthquake bigger than the original one. He seemed so sure. we stopped. the four students left. I stuck around to pack up. On my way out I met one of the nurses who took my class for nurses that just ended Friday. As we walked,she told me that in ICU, there were two patients on the ventilator who could not be moved outside, and as long as they were there, nurses needed to stay inside ICU with them. I told her “I’ll keep you company,” and went to ICU with her.

I got there in time to catch the tail end of a “patient party counseling session” in Hindi language, between one of the senior attending doctors and about six panicky family members who wanted their loved one outside.  The patient was on a mechanical ventilator for which the oxygen came from a large cylinder.  The ventilator could not be run outside.   I thought the doc did a great job of explaining. The family acquiesced and stayed.

I went to look at the parking lot –  in this section there were many patients . I thought about taking a photo but didn’t. I couldn’t judge the mood of the crowd.

And this was Bhairawaha.

Far from the epicenter, far from the crowd.

On Twitter I got an inkling of rumors in Kathmandu. Evidently today the rumor was that a tiger had escaped from the zoo. ( false). and they too heard the rumor about the 3 PM quake that was going to be so powerful ( 3 P.M. came and went.) I read that somebody interviewed a seismologist who said “this isn’t the ‘Big One’ – the ‘Big One’ will be coming later.” and I think that this may have morphed into the rumor. That seismology guy, and the person who published that story needs to know that what he said got changed around until the listeners heard something else entirely. This happens all the time.

So – the power of rumor is alive and well. In USA we’ve had the equivalent force – I recall just before the November election when the Fox News channel seemed to be deliberately spreading lies to whip up hysterical fear about Ebola. But it’s much worse here, where it is easy for the collective opinion to turn into action before any body can stop it. This is a “collective culture” – meaning that the will of the group can overtake reason on the part of individual members and things get out of control.

This illustrates the Number One Rule of Public health: Never do or say anything that will create fear and panic in the general population.  and the authorities here need to establish firm control over the flow of information. The fact that TV seems to have gone down, is not helpful.

This is still a humanitarian disaster of epic proportions

Now, I don’t want to the reader to think I have lost sight of the big picture. Information is still coming in, especially from the hill country of Nepal, and things do not look good. The casualty list continues to grow. The first forty-eight hours is when people will die if they are trapped, and this will happen before the international search and rescue teams arrive. One rule of these international disasters is that the people on the scene have to rescue themselves.

The collectivist culture, by the way, can work both ways. It’s not entirely a bad thing. It can harnessed to create a better situation. If there is anybody who can work in a group to pull people out of the rubble, it’s the Nepali people.

That’s enough for  now.

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From CCNEPal April 26th, 2015 about medical and nursing volunteers in #Nepal after the earthquake


An excellent summary from the New York Times  – click here.

For readers of this blog, you know that I have been teaching critical care nursing in Nepal since 2011 and I have made eight trips here. I am here for the 2014-2015 academic year to continue this work for the past ten months.

I have heard from most, but not all, of my Kathmandu friends. Because I am a foreigner, many people from Kathmandu called me, to see that I was okay.

For the record, I was in Bhairawaha Nepal on the day of the quake. Several hundred miles away. In Bhairawaha, I noticed something odd at 11:56: the water in the glass on my desk was sloshing back and forth all by itself. I immediately got up, alerted the other people nearby that it was an earthquake, and we all left the building. The cacophony of nearby birds signaled that something unusual was happening.

Here, nothing was damaged. Not only that, but it was mild enough that things stayed on the shelves and tables. I spent much of the day (it was my day off) answering emails and messages to re-assure my friends that I was safe.  I am fine. I am not personally inconvenienced in any way.

I am on my long-planned “Road Trip” – fifteen sessions of my course outside the Kathmandu Valley. Five have been completed and ten remain. I am teaching today.

I would point out that CCNEPal, my organization, has trained 1,775 nurses and docs in Life Support skills, and about 800 are in Kathmandu. For that reason, I suppose you could say that CCNEPal has “pre-positioned” for this event (though I would not wish this on anybody).  to all my former students I say – “Go get ’em!”

Pictures I have seen on FaceBook indicate that at least several large hospitals are intact and open for business. Also there is ample capacity to shift medical personnel from other areas of the country that were unaffected, to Kathmandu itself. In the immediate period, this is probably the most effective thing. The problem is going to be getting the nurses and doctors to where they are needed, since the airport will be full and we don’t know the road status.

We know very little about the conditions in rural areas.

I am 100% certain that the Nepalese people will be helping each other, it is something I have always admired about this beautiful country. There is ample capacity to shift medical personnel from within the country, and I am sure that such a move will be easier than to bring in people from outside.  For those who wish to help, I guess the first thing is – send money to aid organization of your choice. (not to me!)

In general, I think it’s too early for nurses and doctors to come here unless they speak fluent Nepali and already know about the hospital system (most hospitals are intact). There are many many Nepali nurses and doctors working abroad, they should be the very first ones to come back here, if anybody does. I do not think the needs will be quite the same as they were directly after Haiti, for example.

From reading about other disasters in other parts of the world, I think that the early period will focus on recovery of victims. The time when foreign nurses can help will be down the road, when disaster fatigue sets in, and also to “backfill”  basic health services in unaffected areas where the Nepali nurses have and doctors have been shifted to Kathmandu.

We will all learn more as the full extent of damage is revealed in coming days.

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CCNEPal “Road Trip” in #Nepal update as of April 20th 2015


UPDATED schedule for Road Trip. CCNEPal has trained more critical care nurses than any other NGO in Nepal, over a wide geographic area.

The session at P.U. in Biratnagar was great – 47 nurses took the training and I also met with administrators who were supportive of the idea of expanding this to every college under the affiliation of P.U., in future.

April 12th 7 13th; 14th & 15th; 16th & 17th; 19th & 20th. Four two-day sessions  of the course at CMC, are now a fond memory for me. The groups were terrific. See the FB page for photos. I worked with the teaching team as they conducted the training while I stayed in background – CMC is fully capable and qualified to train on their own – without me. that has always been the goal. Hooray!

April 21st – travel day from Bharatpur to Bhairawaha. by bus. I will pass the scene of my bus accident. I wonder if the carcass of the bus will be laying there?

April 22nd, 23rd and 24th – three-day session of the Critical Care Course, for nurses at Universal College of Medical Sciences (UCMS) in Bhairawaha. I was there in 2011 and they were wonderful to me.

April 26th & 27th; 28th & 29th; April 30th/May 1st – At UCMS. three two-day sessions of the course, with a focus on medical officers, MBBS students, and interns. The interns will be finishing their time at UCMS, and this course will help them be ready for possible assignment  to smaller health posts.

May 3rd, 4th & 5th – three-day session for UCMS nursing students.

May 6th & 7th  – travel from Bhairawaha to Jumla. By shuttle vehicle. Jumla is in Western Nepal.

May 8th, 9th & 10th; then again 11th, 12th  and 13th – two threeday sessions in Jumla at Karnali Academy of Health Sciences, for hospital nurses, doctors, medical students – everyone. I will be working with the anesthesia department to help them learn how to teach this course.

May 14th & 15th -travel from Jumla to Butwal. Overland. Then a day off May 16th in Butwal, enjoying one of Nepal’s  underappreciated wonders!

May 17th, 18th & 19th – Mayadevi Technical College in Butwal.

May 20th – travel.

May 21st & 22nd, 24th & 25th; 26th & 27th – three 2-day sessions at College of Medical Sciences in Bharatpur.

May 28th – travel to Kathmandu. I suppose you could call it “home” – but – what & where is “home” – that’s what I want to know.

May 29th – one day “make up day ” for small group that was unable to attend LNC session #4 due to bandh. AT LNC.

May 30th – Tribhuwan International Airport. When I get on the plane, I will  look back on a wonderful year in Nepal and India.

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For Nepali MBBS docs who wish to do internship in USA


Going to USA?

This will be brief. A Nepali friend of mine got his MBBS degree last year, has completed his internship, and is working as a Medical Officer. This particular person is one of the brightest and most personable docs I have met in Nepal. (and there are many such).

He told me he wishes to go to USA to take an internship. he’s been to the website of a medical school that has a program he would like to enter. But he asked for help as to how to proceed, because he knew he needed to get USA license. “I know I have to take TOEFL and USMLE but what else do I do?” he asked.

I know there are many other Nepali MBBS graduates studying for USMLE. I don’t consider myself expert on USMLE, or on medical credentials for that matter, but – it looks the rules are very clear: you can’t take USMLE until you have passed the ECFMG process.

I did a websearch and found the site for the Educational Commission for Foreign Medical Graduates. The “about” statement says:

International medical graduates (IMGs) comprise one-quarter of the U.S. physician workforce. Certification by ECFMG is the standard for evaluating the qualifications of these physicians before they enter U.S. graduate medical education (GME), where they provide supervised patient care. ECFMG Certification also is a requirement for IMGs to take Step 3 of the three-step United States Medical Licensing Examination (USMLE) and to obtain an unrestricted license to practice medicine in the United States.

Among other things, you can sign up  for a free electronic newsletter, delivered by email, if you go to their site.

Also, you can start the application process, online.

The Fee?

It’s not free.  the initial application costs 6500 nrs. Before you are finished, if you do the whole process involving USMLE, you pay about $3000 USD, not including the cost of a trip to USA to take USMLE step 2 CS.

Do You know any medical school administrators here in Nepal?

ECMFG has newsletters specifically for medical school administrators. These cover a variety of things, such as how to participate in the international system of hosting USA medical students in Nepal. Please ask your medical school faculty to join this site.

Finally, read my book…….

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April 18, 2015 #Criticalcare Road Trip through #Nepal


CCNEPal is a small #NGO with one mission: teach Advanced Cardiac Life Support  in #Nepal.

For months, we planned a “road trip” outside the Kathmandu Valley with twelve sessions. We made 500 sets of handouts, printed 500 certificates, pre-positioned our teaching supplies, and at each location there was a contact person to alert the future participants as to where and when to appear.

How is it going?

I thought you would never ask!

We now have completed four of the twelve, at P.U. in Biratnagar and CMC in Bharatpur.

The group in Biratnagar was 47, more than my "usual" but I had the help of Dipty Subba and fine support of P.U. administration. We talked about ways to collaborate with the entire P.U. system next year. that would be bindass!

The group in Biratnagar was 47, more than my “usual” but I had the help of Dipty Subba and fine support of P.U. administration. We talked about ways to collaborate with the entire P.U. system next year. that would be bindass!

We teach two similar versions of our class. The 3-day version is for nurses. They have not had as much science as the docs have had, and we spend more time going over ecg when we teach them. The usual curriculum of nursing school has not covered ecg, though more and more B Sc schools are including ecg in their senior year work ( due in part to our promotion of this subject and providing them with teaching materials).

CMC batch #1 of senior MBBS students. Seated are my four assistants for the session - without them the teaching would not have been so good. At each location, the goal is to develop local expertise and experience in running these kind of courses, and I have told CMC administration that I thought CMC was amply ready for this leadership role.

CMC batch #1 of senior MBBS students. Seated are my four assistants for the session – without them the teaching would not have been so good. At each location, the goal is to develop local expertise and experience in running these kind of courses, and I have told CMC administration that I thought CMC was amply ready for this leadership role.

The 2-day version goes straight to the protocols and skills needed to perform and lead a team. We use the protocols of the American Heart Association, with specific adaptations to reflect the current medical practice. For example, certain pieces of equipment are not widely available here and for some of the drugs a less expensive substitute is used.

Note: CCNEPal uses the AHA protocols but we are NOT part of AHA, nor does this course award the participants with the official AHA course completion card for ACLS. Our course is based on the needs of Nepal, and our certificate has little Nepal flags on it. :-)

batch #2. Until 2014, CCNEPal focused mainly on nurse training, and we had trained hundreds of critical care nurses throughout the country in our 3-day course. For MBBS we compress it to two days, and it's go-go-go from the moment we start. the growth they show, in skill and confidence, is rewarding.

batch #2. Until 2014, CCNEPal focused mainly on nurse training, and we had trained hundreds of critical care nurses throughout the country in our 3-day course. For MBBS we compress it to two days, and it’s go-go-go from the moment we start. the growth they show, in skill and confidence, is rewarding.

CCNEPal has taught 62 sessions of this training since it’s inception in 2011. Like in the USA, this is not a lecture class. Consistently, the students are surprised by how practical it is. Much of the class consists of simulated patient situations. The team of instructors guides the student in role play and gives feedback on performance.  There are prop we use to make it more realistic, but we keep these inexpensive and low-tech. For  example, we use a set of child’s playground balls instead of  CPR manikins. These can be deflated for travel.

Batch #3 was also good. there is one more group to come, and I'll add them later. CMC has a high standard for the stduents and I loved the team "vibe" they displayed - the spirit of learning and consulting was excellent.

Batch #3 was also good. there is one more group to come, and I’ll add them later. CMC has a high standard for the stduents and I loved the team “vibe” they displayed – the spirit of learning and consulting was excellent

Right now, the best time for new doctors to take this training is during the final months of  MBBS  program, before beginning their internship year.

UPDATE April 21st

MBBS students are taught to make the most use of resources, in case there is not enough to go around. Batch #4 from CMC showed the same spirit and work ethic as the previous three.

MBBS students are taught to make the most use of resources, in case there is not enough to go around. Batch #4 from CMC showed the same spirit and work ethic as the previous three.

I encourage all the MBBS students to share with others, as to the value of this training. Their testimony and support will do more to promote this than I ever could do…..

In Summary

with eight sessions to go, the Road Trip is turning out very well. The students have been great, and in particular, the support from CMC has been wonderful. In my opinion, CMC needs to develop more as the regional resource for this kind of medical training – they are more accessible for the Terai region than Kathmandu will ever be, and the expertise is excellent.

Want more photos?

In the meantime, you can see a lot more pictures if you go to the FaceBook page for CCNEPal.

The Sacrament of the Goddess – a novel set in a hospital in Nepal

If you wish to learn more about the specific challenges of Nepal health care, you can read one of my two books that described boots-on-the-ground bedside care and decision-making. The second is a novel titled “The Sacrament of the Goddess” – I chose that format to keep it readable.  Click here for a review in Nepali language. You can get this novel in Thamel at Vajra Books, and it has a cult following among young docs and nurses in Nepal. Oh, and it is available in USA too!

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April 6 2015 New Critical Care Book at LNC Library in Sanepa #Nepal


Every nurse in #Nepal is invited to learn about this new resource. It’s perfect if you are doing a research project on ICU care. Or if you wish to learn about mechanical ventilators, for example.

IMG_20150406_064800

This book costs $125 USD (12,500 nrs) and it is considered to be the most comprehensive and authoritative evidence-based procedure manual for ICU in print. The Library at Lalitpur Nursing Campus in Sanepa now has it in the reference section (not for checkout!). It is available to any nurse who wishes to learn from it. You do not need to be a student at LNC to use this resource. If you are going there, call 975 112 1005 to confirm that the library is open.

This book will join the set of American Heart Association books related to BLS, ACLS, PALS, STEMI, and airway now also at LNC.

Here are the books that LNC now owns. Most are from the American Heart Association.  I will also give them the complete set of materials form the pen drive I usually share at sessions of the CCNEPal class

Here are the books that LNC now owns. Most are from the American Heart Association. I will also give them the complete set of materials form the pen drive I usually share at sessions of the CCNEPal class

Here is more information below, taken from the book’s webpage.

Description

AACN Procedure Manual for Critical Care, 6th Ed.

The AACN Procedure Manual for Critical Care, 6th Edition presents procedures for the critical care environment in an illustrated, consistent, and step-by-step format. The Procedures and Patient Monitoring sections are presented in a tabular format that includes special considerations and rationales for each intervention. References have been meticulously reviewed to ensure that the most authoritative and timely standards of practice are used. Additionally, the references supporting care recommendations are identified according to the latest AACN Evidence Leveling System to ensure that you have a complete understanding of the strength of the evidence base.

“The most important aspect of this procedure manual – that sets it apart from ALL the procedure manuals on the market – (is) each procedure is based on the latest evidence and provides a complete EBP (evidence-based practice) resource of critical care procedures. Each step of each procedure has the level of evidence which supports the step.  

Hospitals are struggling with how to insure that their nursing practice is based on the latest evidence – adoption of this procedure manual for a hospital’s critical care units would provide a pain free way to document and verify that critical care nursing practice is evidence-based!”     – Marianne Chulay, RN, PhD, FAAN

Table of Contents:

UNIT I Pulmonary System

Section Editor: Michael W. Day

Section One:

Airway Management

  1. Combitube Insertion and Removal AP
  2. Endotracheal Intubation (Perform) AP
  3. Endotracheal Intubation (Assist)
  4. Endotracheal Tube and Oral Care
  5. Extubation/Decannulation (Perform) AP
  6. Extubation/Decannulation (Assist)
  7. Laryngeal Mask Airway AP
  8. Emergency Cricothyroidotomy (Perform)
  9. Emergency Cricothyroidotomy (Assist)
  10. Nasopharyngeal Airway Insertion
  11. Oropharyngeal Airway Insertion
  12. Suctioning: Endotracheal or Tracheostomy Tube
  13. Tracheal Tube Cuff Care
  14. Tracheostomy Tube Care

Section Two

Special Pulmonary Procedures:

  1. Continuous End-Tidal Carbon Dioxide Monitoring
  2. Continuous Venous Oxygen Saturation Monitoring
  3. Oxygen Saturation Monitoring by Pulse Oximetry
  4. Pronation Therapy

Section Three

Thoracic Cavity Management

  1. Autotransfusion
  2. Chest Tube Placement (Perform) AP
  3. Chest Tube Placement (Assist)
  4. Chest Tube Removal (Perform) AP
  5. Chest Tube Removal (Assist)
  6. Closed Chest Drainage System
  7. Needle Thoracostomy (Perform) AP
  8. Thoracentesis (Perform) AP
  9. Thoracentesis (Assist)

Section Four

Ventilatory Management

  1. Noninvasive Ventilation (CPAP and BiPAP Masks)
  2. Arterial-Venous Oxygen Content Difference (a-v DO2) and Oxygen Transport (Delivery) and Consumption Calculations
  3. Auto-PEEP Calculation
  4. Compliance and Resistance Measurement
  5. Manual Self-Inflating Resuscitation Bag
  6. Indices of Oxygenation
  7. Shunt Calculation
  8. Invasive Mechanical Ventilation (Through an Artificial Airway)—Volume and Pressure Modes
  9. Standard Weaning Criteria –Negative Inspiratory Pressure, Positive End-Expiratory Pressure, Spontaneous Tidal Volume, Vital Capacity, and Rapid Shallow Breathing Index
  10. Weaning Process
  11. Peripheral Nerve Stimulators

UNIT II Cardiovascular System

Section Editor: Debra Wiegand

Section Five

Cardiac Emergencies

  1. Automated External Defibrillation
  2. Cardioversion
  3. Defibrillation (External)
  4. Defibrillation (Internal) AP
  5. Emergent Open Sternotomy (Perform) AP
  6. Emergent Open Sternotomy (Assist)
  7. Pericardiocentesis (Perform) AP
  8. Pericardiocentesis (Assist)

Section Six

Cardiac Pacemakers

  1. Atrial Electrogram
  2. Atrial Overdrive Pacing (Perform) AP
  3. Epicardial Pacing Wire Removal AP
  4. Implantable Cardioverter-Defibrillator
  5. Permanent Pacemaker (Assessing Function)
  6. Temporary Transcutaneous (External) Pacing
  7. Temporary Transvenous Pacemaker Insertion (Perform) AP
  8. Temporary Transvenous and Epicardial Pacing

Section Seven

Circulatory Assist Devices

  1. Intraaortic Balloon Pump Management
  2. Ventricular Assist Devices

Section Eight

Electrocardiographic Leads and Cardiac Monitoring

  1. Electrophysiologic Leads and Cardiac Monitoring
  2. Extra Electrocardiographic Leads: Right Precordial and Left Posterior Leads
  3. Continuous ST-Segment Monitoring
  4. Twelve-Lead Electrocardiogram

Section Nine

Hemodynamic Monitoring

  1. Arterial Catheter Insertion (Perform) AP
  2. Arterial Catheter Insertion (Assist), Care and Removal
  3. Arterial Pressure-Based Cardiac Output Monitoring
  4. Blood Sampling From an Arterial Catheter
  5. Blood Sampling from a Central Venous Catheter
  6. Blood Sampling From a Pulmonary Artery Catheter
  7. Cardiac Output Measurement Techniques (Invasive)
  8. Central Venous Catheter Removal
  9. Central Venous Catheter Site Care
  10. Central Venous/Right Atrial Pressure Monitoring
  11. Left Atrial Catheter: Care and Assisting With Removal
  12. Pulmonary Artery Catheter Insertion (Perform) AP
  13. Pulmonary Artery Catheter Insertion (Assist) and Pressure Monitoring
  14. Pulmonary Artery Catheter Removal
  15. Pulmonary Artery Catheter and Pressure Lines, Troubleshooting
  16. Single- and Multiple-Pressure Transducer Systems

Section Ten

Special Cardiac Procedures

  1. Arterial and Venous Sheath Removal AP
  2. Pericardial Catheter Management
  3. Transesophageal Echocardiography (Assist)

Section Eleven

Vascular Access

  1. Arterial Puncture AP
  2. Central Venous Catheter Insertion (Perform) AP
  3. Central Venous Catheter Insertion (Assist)
  4. Implantable Venous Access Device: Access, Deaccess, and Care AP
  5. Intraosseous Devices
  6. Peripherally Inserted Central Catheter AP

UNIT III Neurologic System

Section Editors: Mary Beth Makic, Teresa Preuss & Debra Wiegand

Section Twelve

Neurologic Monitoring

  1. Bispectral Index Monitoring
  2. Brain Tissue Oxygenation Monitoring: Insertion (Assist), Care, and Troubleshooting
  3. Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), Intracranial Pressure Monitoring, Care, Troubleshooting, and Removal
  4. Combination Intraventricular/Fiberoptic Catheter Insertion (Assist) and Monitoring
  5. Jugular Venous Oxygen Saturation Monitoring: Insertion (Assist), Care, Troubleshooting, and Removal
  6. Lumbar Subarachnoid Catheter Insertion (Assist) for Cerebral Spinal Fluid Pressure Monitoring and Drainage
  7. Intraventricular Catheter with External Transducer for Cerebrospinal Fluid Drainage and Intracranial Pressure Monitoring
  8. Transcranial Doppler Monitoring AP

Section Thirteen

Special Neurologic Procedures

  1. External and Intravascular Warming/Cooling Devices
  2. Lumbar Puncture (Perform) AP
  3. Lumbar Puncture (Assist)

Section Fourteen

Traction Management

  1. Application of Tongs or Halo Ring for Use in Cervical Traction
  2. Halo Ring and Vest Care
  3. Pin Site Care: Cervical Tongs and Halo Pins
  4. Cervical Traction Maintenance

Section Fifteen

Pain Management

  1. Epidural Catheters: Assisting with Insertion and Pain Management
  2. Patient-Controlled Analgesia
  3. Peripheral Nerve Blocks: Assisting with Insertion and Pain Management

UNIT IV Gastrointestinal System

Section Editor: Eleanor Fitzpatrick

Section Sixteen

Special Gastrointestinal Procedures

  1. Esophagogastric Tamponade Tube
  2. Gastric Lavage in Hemorrhage and Overdose
  3. Intraabdominal Pressure Monitoring
  4. Paracentesis (Perform) AP
  5. Paracentesis (Assist)
  6. Peritoneal Lavage (Perform) AP
  7. Peritoneal Lavage (Assist)
  8. Endoscopic Therapy

UNIT V Renal System

Section Editor: Teresa Preuss

Section Seventeen

  1. Continuous Renal Replacement Therapies
  2. Hemodialysis
  3. Peritoneal Dialysis

UNIT VI Hematologic System

Section Eighteen

Fluid Management

  1. Use of a Massive Transfusion Device and a Pressure Infusor Bag

Section Nineteen

Special Hematologic Procedures

  1. Apheresis and Therapeutic Plasma Exchange (Assist)
  2. Bone Marrow Biopsy and Aspiration (Perform) AP
  3. Bone Marrow Biopsy and Aspiration (Assist)

UNIT VII Integumentary System

Section Editor: Mary Beth Makic

Section Twenty

Burn Wound Management

  1. Donor Site Care
  2. Burn Wound Care
  3. Skin Graft Care

Section Twenty-One

Special Integumentary Procedures

  1. Intracompartmental Pressure Monitoring AP
  2. Pressure Redistribution Surfaces: Continual Lateral Rotation Therapy and RotoRest Lateral Rotation Surface
  3. Wound Closure AP
  4. Suture and Staple Removal

Section Twenty-Two

Wound Management

  1. Cleaning, Irrigating, Culturing, and Dressing an Open Wound
  2. Debridement: Pressure Ulcers, Burns, and Wounds AP
  3. Wound Management with Excessive Drainage
  4. Drain Removal
  5. Fecal Containment Devices and Bowel Management System
  6. Negative-Pressure Wound Therapy

UNIT VIII Nutrition

Section Editor: Eleanor Fitzpatrick

  1. Small-Bore Feeding Tube Insertion Using an Electromagnetic Guidance System (CORTRAK )
  2. Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, or Jejunostomy Tube Care
  3. Small-Bore Feeding Tube Insertion and Care

UNIT IX End of Life

Section Editor: Debra Wiegand

  1. Determination of Death in Adult Patients AP
  2. Organ Donation: Identification of Potential Organ Donors, Request for Organ Donation, and Care of the Organ Donor
  3. Cardiac Donation
  4. Withholding and Withdrawing Life-Sustaining Therapy

UNIT X Calculating Medication Doses

Section Editor Eleanor Fitzpatrick

  1. Calculating Doses, Flow Rates, and Administration of Continuous Intravenous Infusions
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