Report of Summer 2017 CCNEPal sessions in Nepal


the first Norvic “batch”included 47 people, more than usual. I had wonderful support from Kavitha Ma’am (the Matron) and Mrs. Mahima Khoju Kunwar, of the Quality department.

Packing up for a long flight

This is a quick summary of activities for summer 2017. The trip this year would not have been viable without the support of a GoFundMe campaign, to which thirteen people contributed. The campaign allowed me to buy the round trip ticket.

We were here for five weeks and taught 13 sessions  to nurses and MBBS docs, in addition to two one-day classes focusing on BLS for BDS students. To be honest, there are many Nepali professionals qualified and capable to teach BLS and it was not an effective use of my time. I don’t plan to do BLS as a standalone, again.

We taught 77 nurses at Lumbini Medical College in Palpa.


Morning tea and biscuits is oh-so-civilized. I love the collegiality imparted by this small ritual. (At Lumbini Medical College).

fifty nurses at Chitwan Medical College, Bharatpur

thirtyeight nurses and MBBS (combined class) at Charak Memorial Hospital in Pokhara;

twentyseven MBBS (intern-level) at College of Medical Sciences, Bharatpur;


teamwork teamwork teamwork. The core of the training is smallgroup work to develop the ability to think on your feet during a crisis.

eightytwo MBBS (intern-level) at Chitwan Medical College in Bharatpur

One Hundred and six nurses at Norvic Hospital, Thapathali Kathmandu; and

twentyone Medical Officers at Norvic.


The total seems to be 364 participants.


r screen that they are looking at a monitor screen hooked up to our Pinnacle tech AT-35. It is an invaluable tool. I left it with my colleagues at Norvic while I am away.

The Original plan was to stay until July 14th, but family concerns arose in USA and I needed to change departure dates.

When I return to USA I will focus on my job as a nursing faculty member, then starting in fall 2017 I will think about next steps for 2018. I wish to build on what I have done to create nationwide network of critical care educators. I think there is need for a nursing-focused course on mechanical ventilation as well as Pediatric Emergencies.



Posted in medical volunteer in Nepal | 1 Comment

Any USA acute care pediatric nurses out there? plan now for summer 2018 in Nepal!

You are now reading the blog to accompany a project that trains Nepali nurses and doctors in critical care skills using a 2- or 3-day course based on the American Advanced Cardiac Life Support (ACLS) course. ( let me be clear: we are not the “official” course). My summer trip for 2017 is a bit shorter than usual, but we still managed to train about 350 nurses and doctors in 13 sessions ( actually, session #13 has not finished quite yet) and BLS to 40 dental students (I don’t usually teach BLS as a standalone course, but that is another story).


I teach a lot of basic skills used in critical care, including ecg. The emphasis is on applying, not just listening to lecture. we use Scenario-based simulation approach” – very active.

Future Plans

I plan to return to Nepal in 2018, and I’m thinking about what the goals would be. To some degree we are still educating people as to what ACLS is and why it is needed. We are making progress on that front, and in the planning for summer 2017 we received many more requests to partner with host sites than we could possibly fulfill.

Building Community

We’re still working to develop more Nepali professionals with the expertise and confidence to lead this course. To truly be an independent teacher of this material requires a lot of experience and confidence, more than you would be able to develop in just a weekend-long “train-the-trainer” course. There needs to be a support system to go along with it, something we take for granted in USA. A sense of community and shared purpose built around the idea that we can prevent excess deaths with better emergency response in this specific area. The people who need the training are the young nurses and docs at the bedside in off hours, and though the “seniors” need to understand it, we have to agree that the “seniors” are not really the ones who need it the most.

Picture 443

Most Americans have a vision of Nepal as a set of quaint villages. It’s true that much of the country is rural, but this project goes mainly to cities large enough to support a medical college and teaching hospitals.


one of our youngest patients

Nepal is a low income country and the profile of illnesses are not quite what you would see in USA. Read my first book, The Hospital at the End of the World, to learn more.

One theme to emerge this year was the specific need for a parallel course in pediatric emergencies. This was requested from a variety of contacts. In USA there are several such courses, the best known being “PALS” – Pediatric Advanced Life Support. So – why not?

I do not believe that PALS should be adopted widely in Nepal lock-stock-and-barrel any more than I believe that the USA ACLS course is appropriate for Nepal. First and foremost, the USA course requires that all sessions and discussions be conducted in English-only, a requirement that is simply ridiculous especially in rural Nepal. Also, the pedagogical framework of the South Asian educational system in which Nepali nurses and doctors are immersed is a consideration. These courses are at their best when they focus on practical hands-on psychomotor skills, and effective training needs to be designed with this in mind.


Having said that, I am interested to find some people with USA acute care pediatric experience who are PALS-I (or PEARS-I, another similar course) who would be interested to come to Nepal in 2018 and teach it. Any takers?

Terms and conditions

the deal would be:

You would pay your own airfare.

You would need to commit to a month here. You would need to study the culture beforehand. No helicoptering in and out.

You would need to agree to use materials and methods appropriate to the audience. No PowerPoint, no long lectures. A good place to start exploring the approach would be the any of the sites that describes “Low Dose High Frequency” (LDHF) training. There are many, just Google the term.

You need to decide in fall 2017 whether you want to do this, because there is a lot to learn before you go the first time.

I should add that I have a friendly relationship with the Center for Medical Simulation here in Kathmandu. They are Nepal’s one-and-only American Heart Association Official International Training Center. If you want to start by teaching the American PALS course as is with no adaptations to Nepal, I am certain they would be thrilled to collaborate with you.

CCNEPal is a grassroots shoestring training operation, and we are looking for like-minded persons who wish to join us as we teach and train. Feel free to browse this site and the related links ( see the column at right). For more info send an email to

Posted in medical volunteer in Nepal | Tagged , , , , , | Leave a comment

Revised Schedule for Summer sessions of CCNEPal 2017

Three weeks shortened from end of schedule

Updated June 24th

I need to update my schedule. I cancelled all the previously-scheduled sessions outside Kathmandu Valley  after June 23rd. I gave the talk in Kirtipur, and will deliver the sessions listed below. I need to do this because in USA, my father will be finishing his course of physical therapy treatments, and I will return there when he is discharged from the Rehabilitation hospital. My brother requested me to go there and so – I will return to USA three weeks early.

Here are the remaining sessions:

15. June 25th, 26th & 27th, 3-day course at Norvic (30+) ( added).

16. June 28th, 29th and 30th, 3-day course at Norvic (30+).

I added the final sessions at Norvic because they had a problem – the ones who took my sessions were extremely enthusiastic and created a sort of jealousy among those unable to register. ( some body does need to cover the patient-care duty, after all). And so we will train more persons. Also, Norvic has been “fun” and I loved the people I met there. It’s a fine hospital.

I also need to “take time and smell the incense….”

I fly out at 0815 July 2nd.

Attitude of Gratitude

I wish to extend my thanks for all the enthusiastic participants who recognize the usefulness of the courses I offer. I thrive on the positive energy. Together we can improve patient care during critical situations throughout Nepal. I hope to return in 2018 and collaborate with all my Nepali friends.

Posted in medical volunteer in Nepal | Tagged , | Leave a comment

Don’t put 10 cc air in the cuff of any endo-tracheal tube

Use the minimal-leak method instead. Described below.

parts of an endo-tracheal tube. (this is of a newer variety with built-in suction port to prevent micro-aspiration). from

In a recent blog, I got lots of hits but very few clicks on the actual video. I decided to rewrite this to focus only on this one specific issue.


Here is a policy and procedure from a major teaching hospital in Texas, USA.

UTMB RESPIRATORY CARE SERVICES PROCEDURE – Minimal Occluding Volume (MOV) or Minimal Leak Technique Policy 7.3.49 Page 1 of 4 Minimal Occluding Volume (MOV) or Minimal Leak Technique Formulated: 11/92 Effective: 11/02/94 Revised: 11/03/14

Continued next page

Minimal Occluding Volume (MOV) Purpose To standardize the method of minimal volume of air in the endotracheal/tracheal cuff that will allow optimal sealing of the airway.
Scope  All intubated patients will be assessed for proper volume/pressure in endotracheal cuffs with each ventilator assessment.

 All tracheostomy patients not utilizing a foam-filled (bivona type) cuff volume/pressures will be monitored on a routine basis.

 The acceptable intra-cuff pressure is less than 25 mmHg.

Audience Respiratory Care Practitioners employed by the Respiratory Care Services Department with the understanding of age specific requirements of the patient population.
Equipment  10cc syringe

 Stethoscope

 Cuff pressure manometer

 Three-way stop cock

 OR Cufflator cuff inflation device

 Manual resuscitator and mask

Step Action
1 Technique for MOV

 Suction the patient airway and oral pharynx to prevent possible aspiration of retained secretions.

 Place your stethoscope diaphragm over the laryngeal area and inflate cuff until all air leak is gone.

 For Positive Pressure Ventilation, remove small increments (0.25-0.50cc) of air from the cuff until a small leak is heard at the point of peak inspiratory pressure (PIP). Check tidal volume to insure adequate ventilation and inflate cuff until all air leak is gone.

 For spontaneous ventilation or CPAP, remove small increments of air (0.25-0.50cc) from cuff until a small expiratory leak is heard (usually in early or mid exhalation). Inflate until all air leakage is gone.

Here is a video showing exactly how to do it:

What if you use too much air?

Using the 10 cc is wrong because it causes “tracheal malacia” and post-extubation stridor. the trachea gets stretched at the point of balloon contact and collapses when air moves out. It can also contribute to tracheal-esophageal fistula. In other words, too much air in the cuff will harm the patient.

Posted in medical volunteer in Nepal | 2 Comments

You are invited to a talk June 21st about Thrashing, plain and simple

Who: Joe Niemczura, RN, MS Principal faculty of CCNEPal

What: Public lecture Violence Against Health Care Workers in Nepal and what can be done about it

When: Wednesday June 21st from 2 PM to 3, then Q & A afterwards

Where: Sociology Department, Tribhuwan University, Kirtipur, Nepal

Why: “Thrashing” is a big problem in South Asia including Nepal.

Abstract: Violence against health care workers is a problem throughout South Asia and has reached a level where doctors in India have promoted an act of parliament to allow doctors to carry handguns to defend themselves. (not yet adopted).  In  Nepal, this issue gains publicity when sensational reports appear in the newspaper, often reaching the level of communal involvement, but the frequency seems to be seriously under-reported, and there is pressure by many stakeholders to minimize the severity of the issue.  CCNEPal is a small group that delivers workshops on critical care skills to doctors and nurses in Nepal since 2011, and we include activities to raise situational awareness among young doctors to prevent difficulties with the patient party. This presentation will address the issue and share future directions to mitigate the problem in Nepal. It will take place at the D

from Kathmandu Post after a thrashing incident. These are not isolated and the problem exists throughout South Asia. Let’s talk about it.

epartment of Sociology and the media and general public are invited.

For further information, call 98010 96822

or email

Posted in medical volunteer in Nepal | Tagged , , | 2 Comments

about mechanical ventilator patient in Nepal

Update:  This one got hundreds of hits, but few clicks on the video and I think I needed to be more focused. I made a separate entry to focus just on the ET tube cuff volume issue.  CLICK HERE for the new one! sure to click on the video!

In this blog, the directions to ET Tube cuff volume amount are near the end. Keep reading!

I think I might do a series of blogs for nurses and Medical Officers in Nepal.

The Snake Man

Yes, that’s me but I don’t take myself as seriously as the title may imply. This is the tenth anniversary of the episode that happened in Tansen at Mission Hospital that gave me the nickname “The Snake Man” and pioneered the use of mechanical ventilation at that place. It was one of the epics of my entire life and the story is told in my first book.

In 2007 I did something that led to one of my nicknames – “the Snake Man” – you can read about it in my first book.

I didn’t actually know anything about snakes or snakebite, at the time. These days I teach about Cardiac resuscitation when I am here in Nepal, but I am sometimes asked if I would talk about nurses responsibility in mechanical ventilation. So recently I spent some time with some nurses. Instead of giving a formal talk I started off by asking questions and having them show me some things to make sure I knew what it was they were doing. I try not to re-teach people stuff they already know.


For my readers not in Nepal, be advised there is no “Respiratory Therapy” profession in Nepal. Ventilators, and indeed critical care, are in the hands of “anesthesiologists” who after all, place ET tubes during surgery. Except of course when they don’t – in many small hospitals anesthesia is supplied by anesthesia technicians. So the doctors are the ones who do the vent settings.

A Canadian friend named Eric Cheng is involved with a small NGO named “Respiratory Care Without Borders,” giving workshops on this field. I don’t think he’s been back lately – RTWB now works in several dozen countries. I am going to browse their site to see what they recommend for books, etc.

This is another example of clinical issues where the nurse needs to be assertive. For example, in the USA if the tube is dislodged, the nurse removes it, uses a Bag-Valve-Mask, and calls the doc. Not every nurse in Nepal is confident or assertive enough to feel comfortable with this decision. Are you? Would you be?

Not every nurse or MBBSW doc knows how to use a BVM for that matter. I specifically require them to learn skills related to this. Including how to clean the darn thing. I wrote an eight-page policy and procedure on this a few years back.

The Pen Drive

In any case, I have decided to create another folder on the pen drive and load some documents and articles there. It’s been awhile since I updated the stuff I give to session participants. I will distribute it from now on. Bring a pen drive to class!

On the internet I found:

a Booklet titled  “Mechanical ventilation for Dummies”:…/8-04-08%20McIntyre.pdf

Here are some video links I liked:

 How to assist at placing an Endotracheal tube (also known as “intubation”)

Here is another. This video goes over care of an endo-tracheal tube including oral care, documenting the proper depth, and repositioning:

Minimal Leak method

Cuffed ET tube

DO NOT PUT 10 cc air in ET Tube cuff. Choose the amount carefully. Use “minimal-leak” procedure:

People asked how much air to put into a cuff. I showed the group how to decide how much air goes into ET tube cuff, using “minimal leak” method.  I think it worthwhile to highlight the need for this specific procedure:


Fifteen minute basic and excellent introductory lecture, first of a series:

Phasing in

There is a zen associated with effective assessment of ventilation. I always referred to this as “Phasing In” but it’s actually got a more technical name, “patient-ventilator dis-synchrony.” It’s when the patient fights the ventilator. A person on a ventilator is ideally mellow and happy; if they are not, you have to figure out why!

Here is an excellent video from Australia about “Patient Ventilator Dis-Synchrony” also known as “phasing in”

I will add to this over coming days, but – this is a start.

Posted in medical volunteer in Nepal | Tagged , , , , , | Leave a comment

CCNEPal critical care training update June 7th 2017

At Charak Hospital we do our small-group scenario practice on the roof, and it reminds me of the “Rooftop Concert” – last public performance of the Beatles.

June 7th update

We’re about to begin this year’s only session in Pokhara. This is my fifth trip here – I spent two weeks in 2016 and led five sessions. Charak Hospital is the venue, and the training hall is on the roof of the building, in full view o fthe Annapurna Range (on a good day).


For those of you new to this blog – welcome! This project began in 2011 with three goals:

  1. train Nepali nurses and doctors in techniques of Advanced Cardiac Life Support based on the American Heart Association ACLS class (plz note that this is not the “official” class – in previous blog entries I describe in detail the hows, whys and wherefores). status: about 3,000 people have completed the course to date in about 97 sessions.
  2. bring attention to the fact that there is such as thing as ACLS and that it is needed. Seems odd to say, but at the beginning there was tremendous resistance to the idea that the need existed. Status: Now there is wider acknowledgement of the utility of this training. Especially for nurses. This training has elevated the role of nursing at the bedside in Nepal.
  3. create a movement within Nepal to “own” this training, not just at PG level, but during the crucial transition from MBBS to intern. It is the young doctors at bedside, often in the middle of the night or out in a rural area, who need the skills taught by this course. status: some medical colleges are sending 100% of their students to CCNEPal; others have unpgraded their training to teach in themselves. CCNEPal wrote a concept paper to strengthen the Nepal Health system and it’s right here on this blog.

You are invited to browse past entries (there are more than 200) to read all aspects of this project.

Here is the remaining schedule:

9. June 7th, 8th, 9th – 3-days course for nurses in Pokhara at Charak Hospital (38!)

June 10th – travel Pokhara back to Chitwan again. The bus goes through Tanahun, a beautiful section of Nepal.

10. June 11th, 12th; Batch #1 of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

11. June 13th,14th; Batch #2 of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

12. June  15th, 16th; – Batch three of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

June 17th – travel back to Kathmandu

13. June 18th, 19th 20th – 3-days course for nurses at Norvic Hospital (30)

June 21st reserved for special event in Kathmandu. At 3 PM that day I will deliver a one-hour guest lecture to the sociology department of T.U. in Kirtipur.

14. June 22nd 23rd, 2-days course for Medical Officers at Norvic (30)

June 24th – travel – back to Bharatpur of course!

15. June 25th, 26th – Batch #4 of four 2-days session for CMC interns (final) (30)

16. June 27, 28; 29th Nurses at Narayana Sandiak Hospital Bharatpur (30)

June 30th and July 1st – If I haven’t gone to Sauraha birdwatching by now I will surely do it. My older brother is an avid birdwatcher and I will look for them in his honor!

July 2017

17. July 2nd and 3rd – Batch #2 of three at CMS for MBBS (30)

18. July 4th and 5th _ Batch #3 of three at CMS for Medical Officers at SMC (“Purano”) (30)

revised total is about 450 if all goes as planned. Seven travel days.

19. July 6th, 7th and 8th – travel. Then two days in Kathmandu to take in the wonders of the city – to stop and smell the incense – and buy souvenirs for my friends and supporters.

20. July 9th, 10th, 11th, National Burn Center, Kirtipur (nurses) (30)

21. July 12th – 13th – National Burn Center, Kirtipur, 2-day for interns (30)

My goal is to teach until I get on the plane! I leave Nepal July 14th at 0815 in the morning from Kathmandu. My Nepal phone number is now working 98010 96822 plz don’t call after 9 PM

email me at

Dates are subject to change. If you are interested to host me or wish to clarify – my Nepali number is now working – 98010 96822 please do not call after 9 PM

Posted in medical volunteer in Nepal | Leave a comment