Team of Quebec Nurse educators to visit Nepal in spring 2019 – want to meet them?


I got a unusual email that led to a phone call.

Hello Joe,

I’m a Canadian nurse and educator, planning a trip to Nepal in the spring.  I have been to Nepal twice before (about 30 years ago) with my husband, we loved the culture and country very much.  In 2012 and 2014 I volunteered (the second time with a 4 person teaching team) in Bangladesh at the Grameen Caledonian College of Nursing.  We offered some workshops to teachers in their nursing program on moving patients safely, CPR, team teaching, skills (venipuncture, etc) and while there we had an opportunity to visit local hospitals and clinics.  Our visit to Nepal would be for about 2 – 3 weeks.
We’ve applied for a small grant to help us come to Nepal to have a similar visit. We’ve been in touch through Nepali friends with the Nursing Dept at Tribhuvan University.  We would also like to connect with a school that offers the ANM program.
In Bangladesh we were able to donate some supplies and equipment through our own fundraising (venipucture arm, cpr mannequins, sliding sheets, etc). We would be prepared to do so in Nepal.
I’ve read your articles before and just thought I’d get in touch to see what suggestions you might have.
Thank you,  Debbi Templeton
.
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This made me smile
How could I ignore such an email? I sometimes get these, and it’s always nice to chat, so I gave her my phone number. We had a delightful conversation. Debbi and her colleagues are just the sort of person who can contribute to nursing education in Nepal.
Ms. Templeton has her BSN from McGill University in Montreal and a MSN from the University of British Columbia. McGill is probably the top nursing program in the country of Canada.
She would be joined by three other nursing educators from the Chateauguay Valley Career Education Centre, located in a rural suburb of Montreal, not far from the border with Vermont, USA. (oh, and her husband, who is not a nurse).
Here is a photo showing the group wearing their kurta in B’desh:

team templeton

Debbi, Kim, Bev, and Daniele

and they toured a tea plantation:

Templeton team (2)

How we can make this work:

Letter

First, for them to get travel funding from the Canadian Government, they need a Nepal host school that would provide them a letter of invitation. As I understand it, such a letter is legally accepted by the Nepal government to allow them to teach nursing while in Nepal.

Previous international travel

This group has volunteered in South Asia in the past, as well as central America. This is not their first trip overseas.

Pokhara? Bharatpur?

Next, they will happily collaborate with Nepali nurse educators while in Nepal. They will start in Kathmandu but they are intrigued by the idea of getting out of Kathmandu Valley.

Contact them:

Debbi Templeton is on FaceBook, send her a friend request and get the dialog going!

Her email address is:

drkbbtempleton@gmail.com. 

This kind of exchange is really wonderful when it works. For me, my blog, the CCNEPal FaceBook page, and the YouTube channel are set up to help westerners prepare for such kind of travel.

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Summary of Summer 2018 CCNEPal activities


This is “late” seeing as how I returned to USA six weeks ago. My job in USA – my “real job” keeps me busy.

Locations and hosts

CCNEPal taught 19 sessions in Nepal in summer 2018, and distributed 593 certificates for our flagship 2-day or 3-day course in Critical Care skills.

CCNEPal taught at:

the National Trauma Center (two sessions),

National Burn Center (two sessions), and

Mediciti Hospital (four sessions).

Then two sessions in Janakpur, following up on the visit of two years ago.

After that, four weeks in Bharatpur. CCNEPal taught College of Medical Sciences interns and nurses, also Narayani Samudayik Hospital and the Zonal Hospital.

Back in Kathmandu, the last session of the summer was at CIWEC Clinic.

Special Guest Colleague

I always put out an announcement for other USA critical care nurses who wish to learn about Nepal health care. This summer, Valerie Aikman, RN, BS,  joined me for the ten weeks.  While I was teaching she was making hospital rounds and applying her experience as a critical care manager alongside the managers of the host institution.  I think people really appreciated her expertise in improving the clinical environment for critical care.

Summer 2019

I plan to seek out other nursing educators for summer 2019 as well. We are always asked to provide specific education on pediatric emergencies but I don’t feel like I personally am qualified to teach this; I don’t have the kind of i-depth knowledge of PALS that I do for ACLS.

At some point I will post a more detailed description of what the experience involves.

 

 

 

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#WarAgainstDoctors in Nepal with #mulukiAeen #WeAreWithYouNMA


NAM

The doctors of Nepal are leading a nationwide protest by shutting down hospital services except for emergency cases, starting today ( well, strictly speaking, yesterday since they are a day ahead of us on the International Date Line). The government revised the criminal code to establish a criminal penalty for the doctor when a patient dies under their care. The Nepal Medical Association called for this to be suspended until it can be replaced, but the government did not respond to a two-week deadline.

“All Doctors Will Be In jail Due to New Criminal Code”

Writing in Setopati ( A Nepal online publication), Dr Chakra Raj Pandey wrote:

Our attention has been drawn to some provisions related to doctors and health practitioners in the new General Criminal Code that came into effect from first Bhadra, 2075 (August 17, 2018).

Clause 230 (1) and (2) is full of flaws. It seems that people who do not know anything about medical science have proposed the clause. In fact, it can take many individuals lives. There is nothing small or big in medicine. One tablet can cause anaphylaxis or one surgical incision can cut nerve or artery or even cause septicemia.

Medical error has been defined as an unintended act or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient. Heart ailments cause 611 thousand, cancer 585 thousand and medical errors 251 thousand deaths, according to statistics from US Hospitals for 2013.

Looking at clause 230 (3) and (4), any of us can be in prison from three years to whole life.

Hippocratic Oath prohibits all of us from treating any patient with wrong intention. If we do so, we are not physicians. In that situation, our license has to be confiscated by the council or other regulatory bodies. …..

Clause 231 (2) a and b treat malicious treatment by physicians like murders. They state that no physician will treat maliciously, and the physician’s license will be confiscated if there is any concern and complaint about malicious treatment. I have never heard and read about any physician treating maliciously in my life. How can a patient go to a physician who is treating maliciously?

Clause 232 talks about medical negligence. Is it medical error or is it a different thing? If we talk about medical error as medical negligence, there will be no space left in the country’s prisons and there will be no doctors left in the hospitals.

He continues:

So, this law has been put forward without enough homework and no stakeholder was invited in the discussion process. It is still not too late to correct it. I am sure with the able leadership of Prime Minister KP Sharma Oli, this problem can be corrected once and for all.

The discussion, in my view, has to be focused on how to produce able doctors, how to provide life-long education, how to participate in maintenance of certification, how to do clinical and basic science research, how to make better hospitals where doctors can perform best surgeries, treat patients in the best possible way, and how to build safe institution.

It seems our focus has deviated from the main goal. Let physicians and allied specialties come together to show the correct path and solidarity.

Background to the issue

The problem is, Nepal is a Low Income Country with tremendous geographical challenges and an underfunded health system. There are many “excess deaths” in all regions of the country, an “excess death” being defined as one which might not have happened if the best possible medical care had been applied.  A number of these inadvertent bad outcomes garner nationwide publicity. Most notably, for example, if a woman dies in childbirth it is not unusual for the relatives to assault the doctor, vandalize the hospital and demand compensation.   The link will take the reader to a partial list of well-publicized incidents maintained by CCNEPal.

Deja Vu, All Over Again

In September 2017, the NMA strongly protested a similar proposal, one that would have also criminalized the practice of medicine. The government ministers have not gotten the message it seems. At that time an editorial in SwasthyaKabar wrote:

Doctors all over Nepal are now hesitant to take any risks by managing complicated cases on their own, thus leading to many unnecessary referrals to higher centers. This is what they call “defensive medicine.”  Many hospitals are not managing serious cases because of the fear of repercussions if anything goes wrong. They are putting their safety first and being defensive, especially in those areas where they are practicing in small groups without much supervision and guidance. This will lead to a significant increase in the number of cases burdening the public health care system, thereby further decreasing quality and increasing the cost of clinical care. Patients will be directly affected if this continues. The patients from the most vulnerable and marginalized population will be the ones most dramatically affected, given that they do not have any alternative, and cannot afford to pay high out of pocket expenditures to go to private clinics. Health care will not be equitable and affordable to all, by any means.

 

Root Cause analysis

The custom in Nepal is to simply blame the doctor. In USA we would “drill down” to examine the safety systems in place to pro-actively identify hazards, but nobody seems to have applied this to Nepal before adopting the new law. For example, determining if the hospital owned the right emergency equipment and whether it was in good repair, or perhaps whether the staff was properly trained. Questions such as whether the patient intentionally delayed going to the hospital or did not enroll in prenatal care.  One international NGO that runs a hospital in Nepal did publish one of their own such analyses recently, and it illustrates the points I  am making.

Transfusions as an illustration

Nepal does not have a consistent blood banking system, but does have a population of citizens with AB+ blood, a situation that becomes dire when the person who needs it is a postpartum woman in hemorrhage. (Not the only problem with Nepal’s system for transfusion.) The way the new law is written,  any doctor unable to obtain AB+ blood for such  a patient can go to jail. If this is allowed to let stand, who in their right mind will risk agreeing to deliver the baby of any woman at risk?

Thrashing of doctors and vandalizing hospitals

This is already an issue in Nepal, and in fact it is a problem in all  South Asia, as has been documented in this very blog you are now reading. Regardless of the circumstances of death, it is a widely known cultural practice to blame the doctor and attempt harm. In the recent past, India and other countries have considered a #JailWithoutBail penalty for any patient party that reacts to bad medical news with violence, modeed after a newla in Queensland, Australia. This new law in Nepal achieves the opposite effect, and increases the likelihood that doctors will get thrashed and the perpetrators will be immune from prosecution.

doctors protest Oct 7th 2017

A prior protest by doctors in India to raise awareness of the risk of being thrashed by angry relatives of a patient. The risk of thrashing has nothing to do with the quality of care being delivered.

There is no central registry of inadvertent deaths

The government has no data of which I am aware, which is why I started the tally of cases that received newspaper coverage. There are many equally serious cases that do not receive coverage because they lack the sensational element.  In my travels around Nepal teaching critical care skills to doctors and nurses, I listen to many anecdotal stories of systems failures.

Government Hospitals

It is crystal clear that any doctor working in an underfunded hospital can easily become a scapegoat.  The biggest most underfunded hospitals in Nepal are the District Hospitals and Regional Hospitals. Even more so in rural areas.  Why would any young doctor take the risk and work in a rural government hospital?

Protest in Kathmandu

Here in Nepali language is a video of a protest march.

These are not the kind of people you ordinarily expect to be out marching.

Other background info

More information as to other new and controversial clauses in the newly revised law are listed here.

Summary

This preset proposal needs to be withdrawn and all stakeholders need to have input.

 

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Teaching when #English is the #Second #Language for the Entire Class #ESL


Pre-emptive announcement:

This blog is directed to my videshi readers. I am pointing out the need for videshis to adapt to the culture of Nepal.  I invite comments but I will only publish if they are respectful. 

Give yourself time to click on every blue link. 

Update: I am told by multiple persons that “code switching” is what I am talking about. I confess my ignorance in not knowing what every else knew! There are ample links about code switching, and anthropologists have popularized this term. I will write an entire blog on code switching in my context,  once I digest them all. Global Health Nurses! Learn to code switch! Here is a ten-minute video from a linguist. 

Update #2 Here is a article specific to code-switching on Nepali TV. Gives good examples!

Nepal

My first trip to Nepal was in 2007 and I come here almost every summer. Since 2011 I have my own project to teach critical care skills to nurses and doctors, but I often run into other western health care people trying to teach this or that skill, or spending time here as part of their professional development. I don’t hang around with mountain climbers in Thamel or EBC.

I am fortunate to enjoy a good reputation for my sessions. Here is  a Nepali-language sample of feedback from a person who took my training:

Travel Back in Time

Seven years ago I once wrote a blog titled “Twelve Steps to Prepare for Global Health Nursing” which made the case for easy ways to learn about the culture of whichever country a nurse might think of going. I re-read it recently and it withstood the test of time. There is one area to add, though, specifically on the topic of teaching nursing in an English-speaking low income country.

Imagine yourself in a classroom with this guy as the teacher:

Now imagine that these guys are your students and this is the level of English they speak.  I have taught many of my sessions outside KTM Valley where this is the level of English possessed by much of the class.

Now imagine this is the lecture you are trying to deliver to those guys:

The American guy in the video obviously knows his stuff. The speaker is knowledgeable, speaks clearly, makes his points including nuances. Tell me honestly,  will they get it? 

The answer is obvious. 1) he talks too fast 2) he uses too many big words 3) he uses complex grammar. 4) not enough time for students to write notes 5) complicated graphics. 5) no pauses for people to process.

He is a terrific lecturer for America audiences but he would be frustrated in Nepal.

There are many Nepali people with excellent English, don’t get me wrong:

Pronunciation

English is not pronounced in Nepal the way you think it is.  Here is some info about  the way words are sounded out:

 

The language of instruction is English,” I have been reminded in about two dozen locales of Nepal, by various and sundry. This is said of Nepal (which was never conquered or colonized), but it also applies to such places as India, Nigeria, Jamaica,  Guyana, Singapore and other former colonies of Britain.

Um, no. It is not. To truly become successful you must understand the idea of hybrid English, also known as “Pidgin.”

ESL

The language of instruction in Nepal is English as a Second Language (“ESL“), not English. There are lots of Americans ( and Brits and Aussies)  who don’t know the difference.  ESL implies that the student’s grasp of English  has very specific limits. In USA these days any given nursing school will always have a subgroup of ESL students, and they often need coaching as to how to grasp “medicalese” – (when you get down to it, most medical professionals don’t speak English either!).

Because of the Medicalese issue, I learned long ago in USA to treat my entire classroom of beginner nursing students as if I was teaching them a foreign language. Think of all the  abbreviations a practicing nurse or doctor will use in daily work. I am very proud to say that my current employer ( a community college) devotes resources to the success of these students.

ESL in USA

Last spring there were some Latina students in my USA lecture class who formed a study group and made this video:

 

Back to Nepal and “Foreign Lands”

The ideal of course, is for every American volunteer abroad to speak and teach in the local language.

When learning the local language is not possible, it is very important to adapt your own language so that it mirrors the English the students speak.  Assess the level of language skill of your listeners very carefully, and reserve your most erudite English only for those at the top tier of English proficiency.  Switch your style to fit the audience.

There are people who get it, and others who keep the same speaking style they use in USA, telling themselves something like “I’ll help people more if I model my mastery of the language and elevate the English comprehension of the listeners.”

Nope. That lasts about a minute. The audience will be lost and confused. They will politely listen because after all, you are a foreigner and you have come such a long way. But if somebody asked them what you just said, they are unable to describe it.

International Conference in Kathmandu

I saw this in the ballroom of Kathmandu’s Hyatt Regency a few years back when a distinguished cardiac surgeon from USA was speaking to two hundred people about developments in mitral valve surgery. I thought it was interesting. But, most Nepalis in my vicinity sat politely, looking at FaceBook on their mobile. The conference was funded by the University in USA that sent the surgeon; they subsidized the conference registration fee for most of the listeners; but the points sailed right over the heads of the people in the chairs.

The Nepalis themselves put on better conferences organized by Nepalis for their own colleagues.

International Conference on USA East Coast

A few years back I also attended an event for Global Health Nursing in which the keynote speaker recycled a scholarly paper to present to an audience that included many academics from USA interested in Global Health, but also many nurses from outside USA. My assessment? She too, failed to read the audience. The nurses from Haiti and Africa in attendance did not quite get it. I wonder, when we send doctorally-prepared nurses abroad, do they use this level of  language? If so, are they really imparting anything of value?

Does Incrementally Erudite Scholarly Presentation lead to cognitive comprehension? 

There is need in global health nursing to use plain language for the benefit of all concerned.

In an ESL classroom, the focus is on the learner and what they comprehend, not on the teacher. It’s a spectrum I suppose, but I am proposing that we slide the marker to the right a bit…… tilt it more toward the learner.

Book culture in Nepal

Back to Nepal. the day-to-day culture here is not one that reads a lot of books. In nursing school here, people don’t study an English-language textbook by themselves. Five students gather round. The person with the best English reads it out loud, then they discuss what they just heard, in Nepali.

Here is a video I found from India, it’s a YouTube summary of a scholarly paper on this as applied in India ( a neighboring country whose language has similar origins to that of Nepal). This makes me want to read the original article! The video is 37 minute long, but it dives in to the subtleties of how English  is spoken in India and ways you can use “code talk.” The examples this person gives are in Hindi, similar in many ways to Nepali (um, Nepali is much more musical and beautiful if you ask me).

This teacher has other videos.

Singlish

Here is a video about the amalgam of Language in Singapore (Um, Not Safe for Work!) . There are surprising parallels to the way English is spoken by many in Nepal, and I know one Nepali nurse whose father was deployed with Gurkhas to Singapore, so her English is almost exactly like that of this narrator:

Online you can find dictionaries of Singlish words.  Specific to India, there is the phenomenon known as “Hobson-Jobson.” In my two books I tried to convey the way certain phrases persist among staff of Nepali mission hospitals.

Hawaii and Maine

I have always loved Pidgin languages. I lived in Maine a long time, famous for a peculiar accent,  and a vocabulary that mixes archaic words from Elizabethan England into English. I can easily speak like a native Mainer and certainly my two daughters are fluent. I also lived in Hawaii, where there is an even more distinct pidgin (you need to click on that link!) that incorporates many  phrases and grammar of Hawaiian language as well as Filipino, Japanese, and Chinese.  I am unable to imitate this at all, due to the inflection and musicality. I totally loved and respected the way this is a living language and the politics of it are fascinating to me. The musicality of an Asian language, and the grammatical differences tend to accentuate the difficulty in hearing what is being said.

Jamaica?

Listen to this one.If you can’t somehow get it, you need to tune your ear:

Some of the points about preparation in my original article reinforce this, such as spending time with the local Nepalis in USA before you depart for Kathmandu, but I think this ESL issue needs emphasis so that you have a clear goal when you are speaking with your American-based Nepali friends and preparing yourself for cultural awareness. It’s about more than just food and prayer flags.

Future blog on this subject?

there are many things I consciously do in my classroom to address this specific challenge, some I have been doing so long  I realize I take them for granted. Here is one specific example:

day Bir 2 a

the actual ten steps of defibrillation are the same whether you learn them in English or in Nepali. I always start each of my own classes by telling the group “you can be expert at resuscitation even if you speak no English whatsoever”

Bullet Points?

In a future blog I will give a list of bullet points for things to focus on when preparing for your own global health teaching experience. Until then, looking forward to your feedback.

In Summary

Add training and study of ESL principles, and even some guided practice, to your to-do list before going to teach nursing outside the boundaries of USA. Even if it is to a country where many speak English, you still need to study the language.  You will be glad you did!

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July 25th 2018 Time to stop and smell the incense in #Kathmandu


So the last teaching session for 2018 finished yesterday.

Final tally: 

sessions: 19

total certificates: 583. These are easy to quantify.

Nursing consultations: many.  Not so easy to quantify, perhaps priceless! Valerie Aikman, RN, BSN is an experienced and qualified nursing administrator and critical care manager who collaborated with administrators at every host agency. I expect that she will share her perspective in future guest blogs on this site. She brought a unique skill set to Nepal.

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Valerie Aikman, R,N, B. S was my colleague this summer. Here she is with Anupama Karnajeet, RN, B Sc who first took my course five years back. Ms. Karnajeet is a critical care specialist in her own right. Her assistance was invaluable.

Last session, back in Kathmandu

We taught 24 nurses from CIWEC hospital. This one was arranged through a former CCNEPal participant now working there, Anupama Karnajeet. CIWEC is located in Lazimpat, convenient to the big hotels and near the former royal palace.  I usually focus on hospitals in other parts of Kathmandu.

Calling Doctor Rajasthani

This training does not use PowerPoint. We do not own expensive manikins. We do not have long periods of lecture. we are hands-on and practical.

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Just a small number of costume items makes training more fun. Doctor Rajasthani is a recurring character in the drama…..

CCNEPal tends to work in Terai these days with only short periods in Kathmandu. They were having construction at the hospital so the venue was the meeting hall of the Himalayan Rescue Association nearby.

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Himalayan Rescue Association has a nice space for class size of thirty.

CIWEC

CIWEC  Hospital has an unusual history. It was originally a Canadian project,since 1982. They cater to travel medicine, about 80% of their admissions are foreign tourists. They are busiest during trekking season, spring and fall. Here is a 15 minute YouTube video (Nepali with English subtitles). The two doctors in the video also speak excellent English for those who care.

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Everest route. If you trek to Everest Base Camp and develop frostbite or HAPE, you will most likely be evacuated to CIWEC. The Tourist Association of Nepal has a system to help injured travelers.

They are famous for treatment of diarrhea, a tourist plague; CIWEC participates in research on this illness.

CIWEC gets patients with frostbite, a problem among climbers. Among the expatriate community of Kathmandu, they are the most highly recommended of any Nepali hospital.

IMG_20180724_180713

Poster in the OPD area. Nobody is downplaying the seriousness of diarrhea, but it’s nice to retain perspective.

Th physical plant is the closest thing to a western hospital, in the country. The mineral content of water here seems to easily corrode plumbing, for example, making faucets difficult to operate. CIWEC does not have this problem. The hospital was remarkably clean and reminded me of my own doctor’s office back in Tampa.

The rooms were nice.

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Most of the inpatient rooms at CIWEC are single-occupancy but some are double. Bright and airy.  The closest to a USA hospital room of any place.

Obviously I just spent three days with the nursing staff. They all were multilingual and spoke good English, as advertised. Many studied or worked overseas.

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The course ” Assistants”for this batch. One of the classroom management techniques I use is to delegate running the megacode drills to people who speak better Nepali than I do!

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brushing up on ecg rhythms. I teach the six step method, the international standard. the class was attentive and sked good questions.

Many previously took either BLS or ACLS and worked in critical care in other hospitals prior to joining CIWEC. The hospital is able to recruit and retain the best.

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part of the three-bed ICU.

Emergency Room at CIWEC

The ER consists of two well-equipped single-stretcher rooms.

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each ER room has’s own ambulance door and an inner door. They have a “minor Operating Theater” adjacent to the ER as well as a larger O.T upstairs. They can do endoscopy.

I wrote relatively little this summer on this blog, I was busy teaching. I expect to backtrack over the fall and fill in the gaps. This will include ideas about summer 2019.

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Monkey Business in Nepal Critical Care Training July 21st


July 22 update the trip back to Kathmandu was uneventful. The temp here is is in the 80s (f)  as opposed to 100 (f) and it is amazingly quiet at night when you don’t run the air con. For some reason my spellcheck keeps correcting it to zircon.

Numbers: eighteen sessions completed, 559 certificates distributed.

We are now in the “Shalom Annex 3” since the regular Shalom is full-up with medical students from Newfoundland. it is near Ekantakuna, a pleasant little chowk. We got groceries and put them on the pantry shelves.

We were chatting on the back porch, when we heard a noise in the kitchen. It was a monkey that snuck in through the window. He had opened the fridge and strewn about some noodles. We scared him away. the neighbors came, so did the other boarders. We learn that this guy has been patrolling the area.

Alas, no photos of the kitchen scene.

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We named our neighbor “Curious George” of course.

July 22nd, 23rd and 24th CIWEC Clinic in Kathmandu. The actual training hall will be at Himalayan Rescue Association in Lazimpat.

July 25th, to Aug 2nd – open dates. we will meet with supporters and friends in Kathmandu…  time to “stop and smell the incense” and there are many persons we wish to meet with before we leave so as to set things up for next year.

August 2nd – rendezvous with TIA for flights to USA.

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July 6th 2018 Update for CCNEPal


UPDATED July 13th

This will be brief.

we now have about two weeks remaining on this trip. We have taught seventeen sessions and given 489 certificates. We will give about a hundred more if all goes to plan.

Valerie Aikman,RN, BSN has been a wonderful addition to the CCNEPal team, offering a level of consultation on nursing issues I was not able to do in the past. I will write more about her in the future. She will most likely write some guest blogs.

Calendar:

July 15th, 16th, 17th Narayani Samadayik, Bharatpur. We will work with a very longtime colleague, Dr. Kalyan Sapkota. This will be a three-day session and include nurses from the District Hospital here.

July 18th, 19th and 20th – one last 3-day session at College of Medical Sciences. for nurses. We have truly enjoyed our collaboration with College of Medical Sciences, and we are discussing how best to work together in future.

mugling road landslide

July  21st – return by airplane back to Kathmandu Valley.  Since monsoon there are more landslides on the Mugling-Narayaghat highway. Since my bus accident a few years back I plan the travel so as to take the fewest bus trips possible. Therefore, a plane ticket. We did take one bus from Janakpur to Chitwan.

July 22nd, 23rd and 24th CIWEC Clinic in Kathmandu. The actual training hall will be at Himalayan Rescue Association in Lazimpat.

July 25th, to Aug 2nd – open dates. we will meet with supporters and friends in Kathmandu…  time to “stop and smell the incense” and there are many persons we wish to meet with before we leave so as to set things up for next year.

August 2nd – rendezvous with TIA for flights to USA.

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