August 23rd 2015 CCNEPal update

I checked the statistical report of blog hits and I see that the home page, and whatever is there, is still getting a lot of hits every day. So – I need to put up something substantive instead of just saying that I was taking a hike.

The Trek is Finished.

My trek along the Appalachian Trail was really fun, though. I hiked 49 miles in one week. This was not anywhere near my best mileage or my best daily mileage – I knew I was out of shape from the beginning and I was not “pushing it.” It was mostly on a flat section with lots of lakes and streams.


For the last ten days I have been in Florida, visiting my parents, who just moved in to “Assisted Living” in Tampa. I have been staying with my sister, the same one who visited me in Nepal.

Washington DC

Tomorrow I will go to Washington DC, and visit my older daughter and her husband. I’m planning to take the Amtrak Train there – I like this mode of travel.


I have been following the Nepal news. Right now they are having a) a bandh in eastern Terai; b) demonstrations in Jumla, Surkhet, and Bhairawaha, along with the Janajatis and Tharuhat; c) the anti-corruption movement in which nurses are protesting the “volunteer system” d) the RRP  agitating for designation Hindu state, which in my view would lead to persecution of Christian Nepalis; e) continued aftershocks; and f) possibility that the new constitution will regress the rights of women (and dalits) to the level before 1990, let alone 2006.

Oh, and I did I forget to mention the earthquake reconstruction from the big one? Or the ongoing issue of medical education, protesting the proliferation of low quality schools?  They have a lot to contend with in Nepal these days.

My book

In my novel, The Sacrament of the Goddess, a major scene takes place with a demonstration in the hospital courtyard while the doctors and nurses are barricaded inside.  This week, there was a police shooting in Kathmandu that led to a huge crowd in the courtyard of TUTH, the largest and most prestigious teaching hospital in the capital. Life imitates art. Of course, the scene in my novel was based some true stories, but still – it was a bit eery. The event at TUTH did not hurt any body. Read the book to find out what happens in the novel…. it is told from the perspective of the health care workers. Caught in the middle.

The only good side? my twitter feed (@CCNEPal2013) includes many Nepali sources and I am making a concerted effort to be better at reading devanagari.  I am gaining more skill in this area.

Future plans

I will resume teaching nursing in USA this fall, in only a few short weeks. I have decided to move to the mainland. More on this later.

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CCNEPal goes trekking August 2015

I will be away from this blog for a few days.

I’ll be backpacking in northern Maine on the Appalachian Trail.

Here is a link from a past trip to that area.

In general, any blog entries on the hike will go to my other blog,

Somehow, I don’t think anybody will miss me. But if you do, please read through the entries at the right and enjoy.

the meantime – best wishes to all my friends, Nepali and videshi alike!

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response to twitter feed about resus roles

Ok I’ve been away from the computer and when I come back I get 42 notifications on Twitter. waaaaay more than usual.. what da heck?

They were all in regards to my comment about being polite during a code.

I confess, I shot from the hip and had not read the LWW article by the doctors from  Madison Wisconsin, cited in the original tweet by ERGoddess.

Step back and share credentials: ICU RN since 1978. started teaching critical care in 1980. University faculty member. Former ACLS I and Regional Faculty. Been working as principal faculty of a project teaching ACLS to med students from five med schools in Nepal. ( that’s this blog…….browse around)

What’s the real problem? role development.  what I see is, people are focusing on the teamwork and communication issues and reacting to those, in these tweets.

To me is shows a deficiency in your original ACLS course. These should have been dealt with when you took your ACLS course. But probably you had the DVD ACLS course, and the people leading the small-group work were not good at de-briefing and focusing on these issues. They probably just stuck to whether you could recall the protocol and drug dosage. That’s the way it goes with the AHA courses -they needed to make sure everyone was singing from the same choirbook and so they instituted rigid rules as to the exact way the course would be taught. But they took the passion out of it.

It’s not one-size-fits-all. some people (men and women) need a kick in the patootie to be more assertive, and others need the exact same kick to tone it down. Used to be, ACLS class was the place to get individualized feedback. I’m a curmudgeon I suppose but, that just doesn’t happen these days.

And because ACLS is “mandatory and required” for all manner of people, the docs are in a mixed group and they can’t actually ask about the issues that matter.

FWIW, in Nepal I work very specifically with role development as you guys are discussing. I have posted a bunch of videos on this subject, but they won’t help you unless you speak Nepali – sorry about that.

Finally, I get the idea that the smacc conference got a bunch of people energized about all these resuscitation issues. I have the idea that they took the exact same content that AHA has so painstakingly developed, and taught it using passionate experts who were able to speak, and unafraid to speak, about all these same issues.  smacc reinvigorated the people who attended. ACLS used to be like that. Now it’s simply “gone corporate”

sorry to drag you here, but – the 140-character limit just isn’t making it….

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part two of debriefing video is now on YouTube July 25th 2015

This will be brief. please read the blog entries over the past few months that address the issue of thrashing of health care workers in Nepal. It’s something every Nepali nurse or doc needs to be aware of.

Ke garne?

You can not always control the behavior of an upset family or crowd of people, but you can become “street smart.” You can analyze the security needs of a workplace. You can set things up so that access is controlled and activities are monitored. You can work with the chowkidars so they know their role. You can identify when the situation is escalating, and how to de-escalate. You can help the family grieve appropriately and stay safe.

First, the scenario itself:

Next the first part of debriefing in which the actors told what they thought:

Now, the debriefing response by the teachers:

click here for the link.

Chitwan Medical College in Bharatpur, where this was filmed, is among the top tier of Teaching Hospitals in Nepal. I appreciate their willingness to do this. They are a training resource for the country.

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Campaign to teach situational awareness to MBBS docs in Nepal Jul 21 2015

All #Nepal nurses and MBBS docs need to read this carefully before viewing the videos of violence against health care workers in Nepal.

Specifically, CLICK HERE to see the video that shows what CCNEPal trains docs and nurses.

(note: in the video, the scenario was a surprise to the responders. The woman wearing the turban is one of the teachers and she does know the scenario. Focus on the family interactions, not the execution of protocol).


CCNEPal is the name for the courses taught by Joe Niemczura, RN, MS of USA when he is in Nepal. Joe was teaching at a PCL nursing school in Nepal since 2007 and there he learned that Nepali nurses and doctors are not taught to deal with emergencies the same way that USA nurses and doctors would be, so he set out to change this. He developed a three-day course (three for nurses; just two days for MBBS docs)  to go over the Advanced Cardiac Life Support skills. He adapted the one from USA to fit the needs of Nepal.

Is thrashing included?

These needs included “What do when the patient party is unhappy with an adverse outcome and threatens to thrash the doctor ( or actually does thrash the doctor)”

This happens. It happens throughout Nepal, and Joe was asked about it everywhere he went. It’s a dirty little secret of Nepal health care. Some docs and hospitals deal with it better than others, and it is unfortunate that somehow the doctor gets blamed if it happens. An angry reaction from the “patient party” is not avoidable, but the skills to keep it under control need to be more widely taught in Nepal.

Lifting the veil of secrecy

Until spring 2015, this was called “the secret scenario” since there was a certain element of surprise involved, and Joe always asked people not to tell others about it unless they had already taken the class. Because this part was a “secret” the main way that people learned about the course was via word-of-mouth from people who had already taken the course. The secrecy allowed the course to possess an element of  suspense and showmanship that left the participants with the feeling of having accomplished something amazing.

That was not enough.

In academic terms, Joe’s assessment was that the Nepal MBBS education needed to emphasize “situational awareness” more than it did. The MBBS docs are taught a methodical system of assessing their patient that is not helpful in a life-threatening emergency. Also, the focus is on patient physiology but it needs to encompass the entire microcosm of possibility that exists in an emergency room.

A recent intern who took this course said (paraphrase)

“Til now it hadn’t occurred to me that I would be directing everything – not just the resuscitation, but the whole team of helpers and also the hospital security and maybe even the police if there was a problem. From now on, I will be much more able to think about pro-actively enlisting the aid I need from all possible directions, not just trying to rely on myself.”

Joe knew he would be returning to USA in Summer 2015. And so, this spring he started to post more specific blogs and videos. Joe no longer followed the secrecy rule. You can find them on YouTube.


There are some warnings about the videos and blogs.

First, the scenarios are acted out, not real, though at times the actors and actresses express deep pain or grief.

Next, sometimes people laugh, which may seem paradoxical. Be advised, any mental health professional will tell you that laughter can be a sign of anxiety, and does not imply disrespect.

The actors portraying the wife and members are selected the day before, based on their acting skills displayed in more mundane scenarios. They are given time to research and prepare. They bring their own costume ( making it more real and more fun). Nobody forces them to be in the role.

Third,  we do this because simulation learning is a critical mode for adult learners such as interns, MBBS docs and nurses. It is an acceptable substitute for actual experience. There is an immediacy that can rarely be achieved using sit-down-and-take-notes lecture style.

Finally, the debriefing is critically important. When we do these as part of the class, we create a methodical build up to mentally prepare the participants to deal with emotionally-laden material – which may even trigger issues that are personal to them. We don’t just spring it on them and we always give people time to frame it in the proper context.  That is handled during the debriefing process. This too, is new to Nepal.

Here is the link to the video. Click here.

Here is the link to the first ( of two) videos that show the debriefing. click here.

Here is the link to the  second debriefing video, which highlights many practical tips in Nepali language, for dealing with this problem. It’s long, but worth it.

Future directions


CCNEPal wishes to acknowledge the support of Chitwan Medical College for this program. CMC is on the cutting edge of MBBS education in Nepal, and provided a living laboratory to explore the best ways to teach this content. CMC was the first MBBS program in Nepal to make this program mandatory for all final-year MBBS students (just before internship year). CMC has an expert staff who can teach this.

Nationwide throughout Nepal

CCNEPal has some specific conclusions

1) the training is effective and is needed by MBBS graduates during their internship year. They should not wait until the post-graduate time to get this training.

2) the skills of situational awareness are needed in mass casualty triage, and natural disaster. The MBBS docs will be on the front lines of this.

3) the program needs to scale up to include all medical schools and nursing schools. There needs to be a funding mechanism to support this during the scale-up phase.

There are twenty MBBS schools in Nepal. CCNEPal has worked with four of them. We believe that each of these needs to develop the expertise to teach this content, both the ACLS portion and the situational awareness portion, at a level of the curriculum earlier than at present (in fact, most schools do not teach this at all).

Join the campaign!

As of July 2015 we are re-evaluating how to move forward. Spreading the awareness is always a good step.

Here are things you can do:

Share this blog, and the videos, with as many people as you can.

If you are a medical student, ask your medical school about developing this.

If you have taken the course already and seen how the scenarios work, start using scenario-based education at your workplace.

We need to educate policymakers and leaders. If you can think of ways to do this, contact us.

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My advice to those seeking to bring back the tourists to Nepal July 19th 2015

I love Nepal and I want them to recover and thrive after their earthquake, but…..

warning: this is not a neat blog. I know it’s disjointed but I’m publishing it anyway. It’s thinking out loud.

please share.

Nepal is desperate to bring back the tourists, and I keep seeing short promotional videos, usually testimonials from some European woman with a lip piercing and she says how safe she feels in Nepal. Or a hotel manager.

I myself have joined the call – I published a blog telling all the docs and nurses that yes-indeed they should visit Nepal. Problem is, I am not a good example to follow… I love Nepal and I was already used to the way things operate here. A first-timer might take a look around and get back on the plane. Nepal is not an easy first Asian country and Kathmandu is not an easy first Asian city…. (like Singapore or Kyoto or Seoul would be).

The appeal based on “it’s not as dangerous as it looks” isn’t going to do it. Even if all of us who love Nepal were to succeed in getting their friends to visit now, it’s just not a large enough number. For that reason, I think these promotions are muddled. People want more than just an invitation. I wonder how much the Nepalis have analyzed their tourists in the past, or whether it “just happened” that they developed a tourism industry.

Frankly, the Nepal news is also full of bad news about how they still can’t write a constitution. The international press is covering the women’s rights issues, and this is creating a problem.  The lack of equal rights for women puts Nepal in the same tourist category as Iraq for a lot of wealthy Westerners who have discretionary money to spend on frills like travel.  When it’s a couple travelling, the woman makes the final decision.  She’ll say “Sorry honey, I don’t want to go there. Let’s hike in (Switzerland/Australia/Scotland) instead.”

Sorry to say it, but it’s true. International tourists will choose to go elsewhere until the government starts to include women and become equal. Sure, there will be people who say “leave that to us Nepalis to decide” but frankly, while they are deciding the government, they are also deciding how Nepal is perceived by  the world. The perception translates into tourist dollars. Trust me.  I just spent two months travelling in India.

Does the C.A. want Nepal to be thrown in the same basket as India?

India was gearing up for world tourism and then – the Delhi rape occurred.  I spent two months in India anyway. For me, I had a fine trip. But – the publicity scared away most other Americans. Things like this get blown out of proportion.  I saw plenty of European women travellers, but few Americans. One horrific crime in a country of 900 million people, and India’s tourism promotion work went down the tube. No amount of marketing will cover this over.

And for Nepal? Nepal is a fine place for women travelers, but Nepal can’t take the risk of seeming “anti-women” or unfriendly to women. Ask the tour operators from India how it’s working for them. Equality for women is a no-brainer for many reasons, but among them is the  impact on the tourism business.

tourism 101

Universities have studied tourism. Here is what they will tell you. There is no such thing as the universal tourist.

I websearched this and found a site from a company that books world travel.  Here is one link that describes five “travel personalities” in a nice way; They ask each person to identify themselves as one of the following:

1) Off the Beaten Path

2) Travelling in Style;

3) With Specific intentions;

4) cultural immersion;

5) Responsible Travellers.

Each category will choose different itineraries and different activities. Tourism policy can be designed to analyze the kind of souvenirs each group will want to bring back ( yes there is actually a market for “Hard Rock Kathmandu” or “My parents climbed Mount Everest and all I got was this lousy T-Shirt”)

There was a classic article that divided tourists in to eight categories, but I can’t seem to find the original. Here is this other list, from memory

Beach vacation – family with small kids and lots of sun and sand

football – travelling to follow a sports team, usually by plane, with a group, drinking lots of beer; these people buy souvenirs with logos of the team ( “Emirates”)

eco-tourists/back to nature tourists – seeing wildlife or doing a nature project.

adventure tourists – off-the-beaten path with no plan or itinerary; ( only 4% of the total of world tourists) ( I suppose the IDF falls into this category)

museum-and-culture tourists – fly to a city, rent a car, go to cathedrals and wine bistros. usually a mature couple. Given that driving is not easy in Nepal, this was never really developed.

habitual tourists – same place each year.

and group tourists – such as to a religious pilgrimage. In Nepal’s case, groups from China; or Habitat for Humanity; or a University group.

How to use this

So my first line of inquiry would be – which categories was Nepal getting before? which specific ones are they now not getting?

Um, scratch the beach vacation right off the list. Nepal is 800 miles from the ocean. Nobody comes here for the sun and swimming. As a matter of fact, there’s a TV adventure fishing show that explores the mean-eating catfish in Nepal’s rivers. Nope.

Obviously, the travel goose that was laying the golden egg was the Everest trek and Annapurna Trek. Every individual climber from a rich country, they say, was paying up to $100,000 US dollars for the permit to climb Everest. And that’s not the entire amount that would be spent.

Each of these places took a hit. First, the second-year-in-a-row closure of Everest due to icefalls on the main glacier ( an icefall is not the same as a snow avalanche, strictly speaking, though they overlap). and at Annapurna, even before the quake, bad publicity from an unseasonable blizzard in October of 2014. ( we all saw it coming, why the trekkers, or the government, did not is a mystery).

These two routes are over used anyway.  There’s other really terrific places to trek that would be just as good.

One problem is, from a Nepali standpoint you can also look at the places where tourism flourished before, and see they are now hurting. Both Thamel, Pokhara, and Sauraha were the jumping off points and staging areas for people before-and-after their trek.  A group lands in Kathmandu, spends three or four days in Thamel; goes on the trek; then cuts loose when they return, splurging on the restaurants and bars of Thamel. Or Pokhara. Since the quakes, the outer parts of Thamel are quiet, with many shops shuttered.

Low Hanging Fruit

The big target, if you ask me, is to lure back the groups of travelers. For this you need to give them a specific pitch that goes beyond “it’s safe now, you can come back” – otherwise they will be asking “Come back? for what?”

You need to give them a purpose. a reason. when they go back from where they came. They need to have a one-sentence description of why they went and what they did there that was unique. They will be at their workplace, standing in the food line of the cafeteria, and people will ask them what they did for vacation. So far, that is what is missing from the marketing.  I can give examples, but this blog is already getting too long……

One last thing

Books and literature about Nepal. Time for the movie version of “The Snow Leopard” or perhaps, a Nepal film and literature festival to be held in New York City. NatGeo needs to do a “Nepal Week” to rival “Shark Week.”

Oh, and if you got this far? go to Amazon and check out one of my two books about Nepal…. the second one is titled “The Sacrament of the Goddess” and it’s an adventure story, soon to be a major motion picture…..

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July 18, 2015 an MBBS doc writes about ACLS for interns

Editor’s note: I was privileged to work with Chitwan Medical College (CMC) in 2015 to train 120 MBBS interns with the 2-day course of Cardiac Life Support from CCNEPal. CMC was a terrific partner and they are now teaching this course at a high standard using their own personnel. In my view, CMC is a model for all MBBS schools in Nepal – this content needs to be shared earlier in the curriculum than  it is now. 

The 120 participants were in their “internship year” – finished with the classroom portion but not quite doctors yet. Ashutosh Jha was among the group and I asked him to share his perspective on the course. Here it is. I added the paragraph headers.

The impending epidemic of heart disease in Nepal

Adverse lifestyle changes accompanying industrialization and urbanization have contributed to a higher prevalence of cardiovascular disease. The incidence and prevalence of cardiovascular disease is rapidly rising in the developing nations. Nepal is not immune to it. Increasing use of tobacco, alcohol, sedentary lifestyle, increasing portion sizes, bad dietary practices have all contributed to a rise in atherosclerosis and coronary heart disease. It is not uncommon for hospitals in Nepal to witness more and more cases of cardiac arrest and unconscious victim. It is a daunting task for doctors, medical students, nurses and other health professional s to prevent the disease from emerging in the first place. But once coronary heart disease occurs, it is even more challenging to take care of those patients in the ER.

Just getting to the hospital is not enough

Imagine your close one having a cardiac arrest and you reach an ER in a medical college in Nepal at 3 in the night. There is a medical officer on duty who has just completed his MBBS from the same college and you rush in with your loved one. You are relieved that you got your loved one to the hospital on time and hope the doctor will take care of him. You summon the doctor and the doctor remains puzzled at what has happened and acts late. How would you feel then??

Here I believe is not the fault of the doctor, but say of the curriculum which has included ACLS on the course but has not put it into practice. The poor doctor stands puzzled not knowing what to do. Had he been through the scenario before, he could have handled the situation properly.

CCNepal’s removes this dilemma from the minds of the budding doctor and builds a sense of confidence that will enable him to tackle the situation properly. It will give him a proactive choice whether to take a decision or not. This will create a win/win situation among the healthcare provider and the patient.

Use of Simulation drills

To be successful in any outcome, we have to begin with the end in mind. The end that we want is a fruitful outcome that focuses on the enhancement of the health of the patient, saving the life of that unconscious victim that comes through the ER doors. To do this we need to put things into practice. CCNepal’s workshop helps us do that by making us go through and practice scenarios that might be encountered in day to day practice. As Aristotle one said “We are what we repeatedly do. Excellence is then not an act, but a habit.”The training focuses on making a habit out of the difficult scenarios a habit. Teaching and learning is done in a fun way, which makes the course even more interesting. There is also a short crash course on the ECG. The “six step approach” of interpreting an ECG, is essential for patient management.


Working in a group in medical practice is essential. CCNepal also promotes the principle of synergy. It enables us to act in a group and work properly on it. A group needs a leader who supervises the group from the front and guides it in difficult situations. The need for leadership in ACLS is imperative. There should be someone overseeing the actions. Group makes patient management highly effective.

The 2 day course took us through the basics of BLS and ACLS. From ambu bags to ECGs to defibrillators. But as after every battle the khukuri must be sharpened, knowledge must also be sharpened and we must continue to improve on our own.

CCNepal workshops will make it possible for us not to depend upon a “Bhideshi” to take the ACLS course but make us independent so the tradition continues. This will allow Nepal to be independent on critical care in the long term.

submitted by Ashutosh Jha, MBBS

Editor’s note: CCNEPal is on hiatus while in USA. To obtain a similar course, contact The Center for Medical Simulation.

This area of medical learning is being scrutinized. At what point in medical education should it be offered? Should it be mandatory? How can it be scaled up to be available for the thousands of nurses and doctors who need it now? What would be the overall cost for the simulation equipment that is needed? How can all this be done in a cost-effective way?

CCNEPal invites other guest contributors.

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