getting a handle on #GlobalSurgery via video links Dec 30 2016


Everything I write is based on a simple premise: If you are a medical professional from a developed country trying out #Globalhealth or #globalsurgery for the first time, you need to know as much as possible before you go. No matter how much you study, the first time is always an eye-opener. Phone me if you have questions or need advice – especially if it’s Nepal.

My belated supplement to Goats and Soda

In April 2016, Goats and Soda did a piece on a surgeon in a challenging environment.

http://www.npr.org/sections/goatsandsoda/2016/04/26/475617180/the-improvisational-surgeon-cardboard-casts-no-power-patients-galore

I thought I would look through YouTube and find some other videos that put the problem in perspective. Here they are:

 

The Birth of the G4 Alliance

 

 

The Right to  Heal

End Fistula

Aloha Medical Mission – from Hawaii – I know these guys. They are amazing. they are self-contained – bringing the whole team with them. This is one way to do it. Brad Wong, MD has also served in the capacity of being the only USA surgeon (with an all-Nepali team) on one of his trips to Nepal. I think this video below captures a lot of the team spirit:

 

My YouTube Channel

I take videos in Nepal when i am there, to show such things as how a nursing school learning lab is equipped. This is not the kind of thing destined to bring me viral fame but I did it for you. To see a playlist, go to https://www.youtube.com/playlist?list=PL05C15E3E2862A608

The TV show “ER”

There are many perspectives on offering your self to serve in a low-resource country. From the videos above, you get the idea of the need. There is a large gap between the medical care of USA and that of the developing world.

From the perspective of the person doing this, the person sitting down and making as rational a plan as possible before stepping out of their comfort zone, it’s an adventure regardless of which country you will go. And yes, the various possible options exist along a spectrum. The TV show “ER” did a sub-plot a few years back in which some of the surgeons-in-training went to a war zone in Africa.

As befits a dramatic series, the team is in over their heads, they are in a war zone, things go horribly wrong – actually this is the nightmare for the surgeons mother ( um, what she doesn’t know won’t hurt her. Tell her you are practicing classical piano every day like Albert Schweitzer did).

My own book is about a USA surgeon in Nepal and is set during the Nepal civil war.  There is a separate blog ( https://sacramentofthegoddess.wwordpress.com) for it.

To read the reviews go to: https://goo.gl/PGTW30

9781632100085-SOTG-Nepalt.indd

Many people decide to read a book only after looking at the back cover. Here’s the one for The Sacrament of the Goddess https://goo.gl/PGTW30

Please share and feel free to comment.

 

 

 

 

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Vandalism and anger at CMC Dec 2016


A pregnant woman died in Terai last week, and the family was overcome by grief. They showed it by angry protests. The doctor is always blamed, regardless of the facts. This is an issue that prevents young doctors from wanting to serve in rural areas. Here is more info. The news was sad for me:

Description

Alert: Chitwan/Dec 7, Birami ko mrityu pachhi aakroshit aafanta haru dwara Budhabar Chitwan Medical College ma todfod, 3 prahari sahit 4 ghaite.

The kin of a pregnant woman who died at Chitwan Medical College vandalised the hospital today.

Sunita Gurung, 25, of Bharatpur sub-metropolis was admitted to the hospital after she complained of labour pain. After Gurung died last Monday, her relatives have been staging protests saying that she died due to doctors’ negligence. The irate kin also damaged the glass of the hospital’s main door.

DSP Dipak Shrestha of District Police Office, Chitwan, said four persons, including three police personnel were injured when agitators pelted stones at the police when the latter reached the site to control the mob.

Soman Singh Gurung, family member of the deceased, said Binam Gurung was injured in the incident. Police have arrested five persons and kept them in custody for being involved in vandalism, informed DSP Shrestha.

The victim’s family, however, claimed that seven persons, including one woman were arrested. DSP Shrestha said five were held for vandalism and attack against police.

Soman Singh said Sunita was admitted in the hospital at 3:30am last Monday after she underwent labour pain.

He said Sunita died at 12 noon though the doctors had assured them that she would deliver the baby in two hours without surgery.

The deceased’s sister Gori accused that Sunita had died due to negligence on the part of doctors.

“The doctors had told us that she would deliver the baby naturally. But she lost her life due to the doctors’ negligence,” charged Gori.

The agitating kin have demanded action against guilty doctors. They submitted a memorandum to the CDO today seeking action against the guilty and compensation for the bereaved family.

Issuing a press statement today, the hospital said Sunita had died after she suddenly developed Eclampsia, a condition in which one or more seizures occur in a pregnant woman suffering from high blood pressure, and she died while being treated at the ICU.

The statement read that the deceased’s family members had signed an agreement paper on her treatment and they were informed about the complications that could develop later.

The hospital also condemned the vandalism and manhandling of doctors, nurses, and other staffers after the woman’s death.

https://nepalmonitor.org/reports/view/12517

For the victim and her family

My condolences to the victim and her family. We do not know the details of her illness, other than being “eclampsia.”  The hospital is probably not allowed to release details. There is a lot we don’t know.

OBS at CMC

This is not an area I interface with as a rule. I teach people about teamwork and communication which is universal, but I do not address obstetrical emergencies per se. I don’t hang around the maternity department at any of the locations I teach.

CMC

In My opinion, CMC is among the very best hospitals in Nepal. I worked with them extensively over the past five years to address the constellation of issues related to angry patient parties who vandalize or thrash hospital staff.  The reader can browse about thrity past blog entries that describe aspects of the thrashing issue.  De-escalation, building design, role of security personnel, situational awareness for doctors – it’s all there.

Thrashing

This is eerily similar to the event that caused me to work on the issue of thrashing, which took place in 2009. It was very tense and became the basis of my second book, The Sacrament of the Goddess. You can buy The Sacrament of the Goddess on Amazon, here is the URL https://goo.gl/PGTW30 and there is a blog specifically devoted to the book – https://sacramentofthegoddess.wordpress.com/

9781632100085-SOTG-Nepalt.indd

Many people decide to read a book only after looking at the back cover. Here’s the one for The Sacrament of the Goddess https://goo.gl/PGTW30

 

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Arranged Marriage with Nepali guy in USA on H1-B visa? read about the H4 visa issue, here


As you know, I travel to Nepal to teach critical care skills to nurses and doctors. My goal is to improve the skill level and have a positive impact on health outcomes in Nepal. One of the challenges for me is that so many of the people I train take their skills to Australia or the UK or USA. I think I have trained 150 nurses now in Sydney!

The Big Question

I was very frequently asked “How can I be a nurse in USA?”

My first reaction was “Don’t. Nepal needs you, right here.”

Then after awhile, I realized I might as well put my answer in writing and refer people to this blog. It saved me time, since I no longer needed to answer the question.

“go to the blog. It’s all there.”

How to go to USA and lose your skills.

Often, the kind of person who is going to USA is a Nepali nurse who has specialized skills in Nepal and a high-status job such as in an ICU or specialty area. Now, I personally know some Nepali nurses now in USA who are, for example working in Labor and Delivery or ICU; but more often these persons accept a job in a different specialty. In USA there is  a shortage of nurses who will work in Geriatrics, and many times this is where the foreign nurses work. You need to be prepared to take such a job if you can’t find the one you want.

Today’s new information to read.

I had sort of heard about the H4 visa problem, but not really paid attention until this past weekend. There was a very informative article about visa categories written by a person from India, in their blog.

Here is the problem:

If you marry a guy who is on an H1-B visa, you are given a spouse’s visa (H4) which allows you to be in USA, but specifically prevents you from working. The article described spouses from India, but it also applies to Nepali spouses.

And then there’s the huge cohort of Indian women whose careers are unravelling far away from home—in the United States of America. In the world’s biggest economy, these women are unencumbered by many of the social challenges those in India often face. Yet, their professional lives are being cut short. The culprit is a class of visa that is almost Victorian in its restrictions. (from: http://qz.com/797831/the-h4-visa-and-the-desperation-of-indian-housewives-in-america/?utm_source=KWFBUSQZ&kwp_0=273980 )

Let me be clear: this does not apply if the guy is in USA with a Green Card or if he is a citizen. I am unclear if it applies when the guy is on a J-1 visa ( i.e., a 10-year medical visa) – maybe some of the readers can help.

The entire article is well worth the read for those thinking of this route to USA.

There is a YouTube video that also describes this problem. https://youtu.be/Nj34k6fLpf4

And of course, a FaceBook page you might want to “like” https://www.facebook.com/H4visaacurse/

If you go to the list of top posts from this blog (on the right of this page) you will see that the most popular ones deal with the ins and outs of leaving Nepal to work. (and of course, to see the world). You are invited to browse all of them and become an expert. If you must go abroad, you need to have your eyes open and know how to navigate.

I should add, you can address this problem by doing the extra paperwork for you own H1-B visa ahead of time, or converting over to one when you get there. But it add weeks or months to the timetable. so – be aware of it from the beginning.

Finally, if you got this far.

I have written two books, and they are both available on Amazon.

The Hospital at the End of the World  https://www.amazon.com/Hospital-at-End-World/dp/1935514288  tells about my first trip to Nepal. I tried to prepare as best I could, but it was clear I didn’t really know what I was getting into. I wrote the book to inform future global nursing volunteers as to what it was like.

The second book is The Sacrament of the Goddess. https://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029  This one is a novel. It’s set in a hospital in Nepal during the civil war, and the people in it are forced to deal with crisis. I wanted to explore the ways that Buddhism influences choice made under stress. It’s also a honking good adventure story.  Click here to browse the blog for The Sacrament of the Goddess. https://sacramentofthegoddess.wordpress.com/

You can get The Sacrament of the Goddess at Tibetan Books in Thamel.

 

 

 

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Nepal nurse takes NCLEX and the result is……. ????


Seems like every Nepali nurses is curious about NCLEX

A Nepali nurse-friend now in California told me she passed NCLEX, and I invited her to write a guest blog. It’s lightly edited  – I broke it up into more paragraphs and added the subtitles. Look to the menu on the right and you’ll see the previous entries on this subject. Feel free to share and comment!

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Hi everyone! This is Usha and guess what happened recently.. I passed the N-Clex RN. I’m so happy and I’m grateful for having studied and learning so much even though I don’t like the idea of taking test at the end. Let me introduce myself. So, I come from a beautiful city in Nepal named Pokhara and I came to  United States in Aug 2014, applied for the California Board of Nursing in Jan 2015, got my ATT on Feb 2016 and here I am, finally an RN.

So now lets talk about the test. Taking the N- Clex test is stressful but you know what it’s rewarding at the end! I took off from work and joined Kaplan like 2 months before the test and started practicing questions from UWorld 3 weeks prior test. I found UWorld really helpful because it has varieties of N- Clex type questions that you can practice everyday. It also has a lot of information and diagrams inside each answers at the time of review just to make you understand in a simple way. I made notes out of it. Almost half of the questions that I had on the test were SATA, a lot of priority, one put the order, no click the spot, no drug calculation, no pictures, some meds and ECG questions. The questions are different for everyone though.

But all of these doesn’t matter. What matters is how well you can apply the things that you studied and also from your general knowledge when you answer the questions. I would also recommend nurses to know themselves first before starting to study for the test, because once you know your strengths and weaknesses, you can work accordingly and make a plan and achieve success. (Tip that worked for me during the test: Take deep breaths in between pat on your back, massage yourself on your neck, hands and legs and try to relax. Do whatever that works for you.)

Quick shut off?

It is surprising when the questions shut off at 75. You don’t know if you passed or failed. I thought I failed. But at the same time I thought if I did that bad. That evening, I applied the trick from youtube and I got a pop op saying that I’m already registered for taking the test (denotes positive result) which gave me some hope.

After 3 days I saw my name on the California board of Nursing website where it was written Usha Devkota, RN with license no. and I was shocked and had eyes full of tears. I said to myself that I did it! So yeah, life is complicated but it’s up to us to balance it out. Sometimes things can go positive and sometimes it can go wrong. But never lose hope, stay strong, believe in yourself and go on and I bet every single nurse can pass the test with handwork.

I want to thank every single person who believed in me throughout this phase. Thank you so much!

Usha Devkota

RN

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Bharatpur/Chitwan is the “Medical City” of Terai part one Oct 11th 2016


 

cmc-master-plan-1

from the CMC website, architects drawing. Like most of the big hospitals, CMC is perpetually under construction. But they are well on their way!

Bharatpur, Nepal is located where the east-west highway  intersects with the highway to Kathmandu and Pokhara. Tourists going to Chitwan National Park to see wildlife go through Bharatpur on the bus. Because of the location, Bharatpur is home to four major hospitals.

College of Medical Sciences Teaching Hospital; (also known as “Purano Medical College”) http://www.cmsnepal.edu.np/

Chitwan Medical College Teaching Hospital; http://www.cmc.edu.np/

the Bharatpur District Hospital http://bharatpurhospital.gov.np/, and

the B.P. Koirala Memorial Cancer Hospitalhttp://www.bpkmch.org.np/

Each of these has their own sprawling complex. There are many smaller ones such as Pushpanjali Community Hospital.

There are fourteen nursing schools in greater Bharatpur.

I’m doing a series of entries on the places I teach when I am in Nepal. I’ve already described Janakpur and Biratnagar as well the National Burn Center in Kirtipur. I would be remiss if I didn’t describe the ones in this city. The challenge is, I spent a lot of time here and I know many people – it’s hard to do justice!

In general, institutions in Bharatpur do not have the kind of hosting arrangements enjoyed by some of the places in Kathmandu enjoy. They all express the interest in developing contacts. If you are from USA and you are looking for a potential partner to collaborate with, Bharatpur is a prime site for such things. Let me know.

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This was new in 2016. it’s about one km from CMC.

You can get organic coffee in Bharatpur these days. When I was there in 2016, I learned that CMC is leasing space for a Lavazza coffee café just inside,off the main entrance.

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site of future Lavazza coffee shop at CMC lobby floor CMC has also contracted out with a bank to put a branch on the premises, to handle all patient accounts.

Focus on Chitwan Medical College (CMC)

http://www.cmc.edu.np/

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the front entrance of CMC. Because CMC is at the top of the hill east of the downtown, it presents an imposing view from far away. this is close and doesn’t do it justice…

the main feature of the ground floor is an interior plaza

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looking down onto the plaza from fourth floor. Judging by the uniform, these are MBBS students. It’s a grand spot for morning conference

CMC has four ICUs.

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One of the ICUs at CMC. Dust is pervasive in this climate. To enter this ICU requires going through a sort of airlock that keeps the dust down

another ICU. they’ve recently reconfigured their ICUs and relocated.

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surgical ICU at CMC

Nisha Bhandari is one of the senior nurses. She helped CCNEPal when we did four sessions in a row to train 120 MBBS sessions, and now she also does inservice training for other activities.

cmc-faculty-development-workshop

CMC’s 2016 faculty development workshop. Dr. Rano M. Piryani, is third from left in front row, he has been strong advocate for critical care skills collaboration. Mr. Siddeshwor Angadi of the nursing faculty s seated o the right end in front row, he’s my main colleague for day to day teaching.

CMC does an annual faculty development workshop for all disciplines.

Health Professional Education and Research Center.

HPERC is a new initiative of CMC. In the Nepali MBBS education system, , each batch of interns leaves for a year or two working as a Medical Officer. There is incentive for them to accept assignment in a rural or under-served area. HPERC is designed to provide Continuing Medical Education to this group, so they will more easily advance to post-graduate (PG) level and ultimately, training as a specialist with the title of “MD”

Ultimately all Medical Colleges are destined to develop a similar setup.

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generally the mechanical ventilators are from European maufacturers. Like other major hospitals, CMC has four or five different models.

 

Nurses desk at Emergency Room

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this also is well-lit and busy.

a few pictures of emergency equipment setup.

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med drawer. throughout Nepal this is the standard setup. somewhere along the way everybody decided to do it this way. note that each ampule sits on cotton wadding to mitigate breakage

and another:

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this is what you see when you pull out the drawer.

One of the defibrillators

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CMC owns more than one defibrillator, and this time around we used the above for training. It’s not my favorite. The nice one ( Nihon-Kohden) was in use in their cath lab.

tour of fundamentals lab at CMC

tour of midwifery lab part one.  Siddeshwor took me on a tour of the nursing education facilities, in a different part of town from the Teaching Hospital. I’m always interested to see what kind of learning lab they have.

tour of midwifery part two

next

On YouTube I posted a series of interviews with nursing leaders, and here is one with the Matron of CMC. In Nepali.

There are not many psyche nurses in Nepal, and Mr. Ramesh Subba is a resource.

I’ve previously described the AT-35 rhythm generator. The video below shows what it does, I took this at CMC back along.  (2013)

I have more pictures of the training and the people, but I think this is enough for now. I do not conduct sessions at the District Hospital, but I have pictures of it and many of their nurses have previously taken my training when they were students at CMC or CMS.

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what you need to know about Scrub Typhus in Chitwan, Nepal Oct 11th 2016


http://emedicine.medscape.com/article/971797This caught my eye yesterday:

RATNANAGAR, Oct 10: As many as 59 new cases of scrub typhus infection have been reported in Chitwan district in Asoj, pushing the number of patients in the district to 264 in the last six months.

According to the Insect Controller Inspector at the District Public Health, Chitwan, Ram Kumar KC, this bacterial disease has already claimed two lives in the district so far.

A total of eight persons have been reported dead due to the infection since its outbreak in the eastern part of the country, shared Resham Lamicchane, Public Health Officer at the Epidemiology and Disease Control Division under the Ministry of Health.

According to him, scrub typhus cases have been reported from 37 districts. RSS from Republika http://www.myrepublica.com/news/7173

Is That It?!?!?!

Yes. Normally I only excerpt a longer article – but that’s the whole enchilada right there.

Okay, it’s Dasain, and nobody is reading the papers and nobody is really writing any actual journalism it seems.  (this blog gets noticeably fewer hits as well). Here is my  problem. The article tells us there is an outbreak  – that is good. But it tells nothing about what the symptoms are, how to prevent exposure, whether the treatment works, etc.  They  reported it, yes; but they could have also done a public service.

Fortunately we have the internet.

Here, as a public service, is some info about scrub typhus. Now, I am a person who reads about deadly infectious diseases just “for fun” and enjoyment. ( I think I need to get out more). Next, the other name for scrub typhus is – Tsutsugamushi disease. I laughed out loud, because I always loved that word. An MD friend of mine once did a locum tenans job in Brownsville Texas and told me it was endemic there – about the only place in the USA he said.

scrub-typhus-eschar

from http://emedicine.medscape.com/article/971797-overview this lesion is very closely associated with scrub typhus. When you find it, go to the hospital for antibiotics. It may be under the clothes in an uninspected area.

Preventive measures?

Preventive measures in endemic areas include the following:

For those who do not know the location, it is Ratnanagar – just east of Bharatpur/Narayangarh. You go through Ratnanagar to get to Chitwan National Park.

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(my photo) Rush hour in Sauraha, next to Chitwan National Park. This is what the tourists see. Most cities do not actually have these.

People go through Ratnanagar but (the tourists anyway) do not stop.  In Chitwan national Park one popular activity for tourists is to take a nature hike. Use insect repellant if you do.

Chloramphenicol

Interestingly, it is treatable with antibiotics. One option is Chloroamphenicol, an antibiotic no longer in use in USA. There is no vaccine.

An excellent monograph from USA’s NIH

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829893/ this gives a technical analysis of the “laboratory bench” diagnostic tools. In the meantime, if you have a patient with febrile illness, look for the eschar; and consider the possibility of scrub typhus. In Nepal, it seems more likely in Terai, but at this time of year, people travel for Dasain, the big homecoming holiday.

something every nurse and doctor who reads this, can do.

use your smartphone to show the picture of the eschar to all your  colleagues, esp if you work in a clinic or emergency room.

If your patient has recently travelled to Terai and returned to Kathmandu, be on the lookout!

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CCNEPal goes to Norvic Hospital, Kathmandu August 2016 – some pics


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the cafeteria at Norvic was restaurant quality, with a waitstaff. The canopy was covered by a blue tarp, giving it a distinctive look.

In August 2016 CCNEPal conducted a session of the three-day course at Norvic Hospital in Thapathali, a neighborhood of Kathmandu right near the river. This was not the original plan, but turned out to be fortuitous and fun.

Web page

go to http://www.norvichospital.com/ and take a look. Norvic comes with an impressive list of “firsts” – first private hospital, home of the first cardiologist in Nepal, first cath lab in Nepal, etc. The School of Nursing at Norvic has a FaceBook page https://www.facebook.com/NorvicEducations

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this is not directly clinical “first” compared to angioplasty, etc. But – medical waste is a looming challenge in Nepal and Norvic seems to have designed a system for handling it. bravo!

Norvic is probably the best hospital in the country. I know I know I know, quality is elusive and arbitrary.  Also I know hundreds of nurses and doctors and I should be careful not to offend anybody since there are many wonderful people who work elsewhere. Also, on each of the two occasions when I was sick or injured enough to go to the hospital, it turns out that Norvic was not where I actually went, after all. But I liked a lot of things they did, and if I were sick and had a choice, Norvic is where I would go.

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In Kathmandu mid-morning chiya and biscuits are just the thing. Before the CCNEPal project is through, we will consume one million cups of chiya and two million biscuits. and I always ask the participants to toast – they toast the previous groups and the future groups. ( note: a few people got nescafe – OMG!)

I’ve not previously conducted training with them on their turf, though in the past (2013) they cycled their entire cath lab staff through my series of trainings at Lalitpur Nursing Campus. Most of the cath lab staff were new since then but several had previously taken my course.

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In Norvic cath lab. lead aprons neatly stowed. ship shape!

My contact person was Mahima Khoju, RN, BSN. Mrs. Khoju got her nursing degree from the University of Texas at Arlington, back along. I think we emailed back and forth for six years before we finally met in person.

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Mrs. Mahima Khoju, my contact person. If her friends from UTA could see her now…. actually, the head gear is not her usual, it’s the same puggri every body else tries on sooner or later, my favorite prop for the course.

Cath Lab at Norvic  – I got the tour, but the video was cut short when the battery died.

patient care areas

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one of the Medical Wards at Norvic. light and airy and dust free.

Above is the layout of the medical-surgical wards. two nurses are standing with the dressing cart. it was time for morning care, and all the drapes were pulled.

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a small Newari temple in a courtyard on the premises of Norvic.

Heart Command Center

The tour focused on the ICUs in the hospital. For the Heart Command Center, one  of the staff nurses gave me a specific commentary on the equipment. This is probably boring to anybody who is not an ICU nurse, but if you are? it’s dedicated to YOU!

the above gives you an idea of the equipment they have. I was interested in the external pacer box. Pacing is a thing with me. Nepal needs a more coordinated national system of how to get it for people who need it. we take it for granted in USA, but for many outlying regions if you need it you won’t get it unless you can make it to a place that has it…..

here is a poster that they still display to celebrate World Heart Day from a few years back:

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sort of a re-union of heart patients.

MONA

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In the ACLS protocol, “MONA” is a mnemonic device to recall certain drugs we use. I have a long-running joke about MONA, and MONA appears in my handouts. CCNEPal has trained 2,885 nurses and doctors, and only two were actually *named* Mona. So – we had a running joke for several days. Childish? mebbe. Fun? definitely!

Tokens of love

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the group picture. the 23rd of 24 groups for summer 2016. probably one of the top five groups in the history of CCNEPal ( the others being MMCVTC, SHNHC, the 2011 LNC BN group, and one other whom I shall not name).

Just me and the guys

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“The guys” wanted a picture.  Men do not attend nursing school per se,  but there is a parallel PCL course named “Health assistant”  that enrolls males.  I loved their attitude and sense of humor.

 

Haku Patasi

The final day was wrapped up with a ceremony, as always. My hosts asked me ahead of time if I had any preference for a “token of love” – and I told them. So I was delighted to be presented with two “haku patasi” and a hand-carved tea box with Ilam tea in it.

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made of Nepal-grown homespun cotton, the traditional sari of Newari women. These were for my daughters. Not the usual souvenir of Nepal.

 

 

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