Janakpur visit summer 2016, part one – the town


I spent the summer of 2016 teaching the CCNEPal course in Nepal, mostly in Terai. I was invited to teach in Janakpur, in eastern Terai for two weeks. It turned out to be a highlight of the summer. I am proud of what I was able to help them accomplish there. I am writing two blogs about Janakpur. The first one will just tell about the town and the second will focus on the medical scene there.

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The Janiki Mandir celebrates the Ramayana, a famous Vedic epic from ancient times.

Janakpur is in an out-of-the-way section of Nepal, and it is a miniature version of Benares in many ways. The main language is Maithili, not Nepali or Hindi.

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Hanuman figures in the tale of Ram and Sita, and so there is a temple for him. The woman in the picture offers puja at a bo tree on the ground of the Hanuman Mandir

The Town

This is still in progress but I thought I would publish the rough version.

To learn about the town, there still is no better place to start than the BBC series on railways in India, that features the last railway in Nepal:

The tracks are being completely redone, and the railway station is not serving any travelers. I was told that during monsoon, the only way to get to the villages along the rail line is by the train – none of the roads are passable. People living there need to have all their supplies in, before the rain starts.

Summer monsoon 2016

I left the eastern Terai one day before the serious rains started.  Above is an aerial view of the floods as they impacted Janakpur. This is no joke!

The bus stop

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yes folks, this is how I roll in Terai. This one was going to Itahari, from Itahari I transferred to the Biratnagar bus. On the Biratnagar bus I received a marriage proposal. I declined.

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the main truck route through Janakpur. You’ll know you have arrived when you see the fanciful gateway. directly east of the gateway about five blocks, is the Janaki Mandir. the highway itself at this point, is not scenic.

helpful guy at the ticket shop

There are few English speakers likely to be found at the bus stop. Look for this shop on the western side of the road, and this guy. He speaks English and is very friendly and helpful.

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on the west side of the highway this guy in the white t-shirt speaks English and was friendly.

here is a better shot of the guy, his name is Ram.

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Agriculture activity

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out front of the JHCRC hospital one morning. they are taking the bamboo to a construction site.

One Planet

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the local dalits keep pigs and eat pork – something no Hindu or Muslim would do. A squad of pigs roams the town. In public health, there is a movement known as “One Planet” which acknowledges that when humans live in close proximity to animals, both domestic and wild, the health of all must be considered, not just homo sapiens

Cyber Cafe

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wi fi was available at the hospital, but I found the one and only cyber café in town. reasonable rates. not far from Janiki Mandir, on the road to the zonal hospital.

I stayed on the premises of the host hospital, but most foreigners go to one particular hotel downtown:

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my hosts offered to put me up here, it’s where most westerners stay. But I was fine with the accommodations at JHCRC. I never did eat at this restaurant either.

While we are at it, in the vicinity of the hotel is the one and only “Department Store” of Janakpur. I always check to see if they have a) “organic coffee”  and b) peanut butter. They did not stock either item. They did carry many other western items though.

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the main drag of Janakpur goes from Ganga Taal to the railway station. at the back of this alleyway is the department store. They did not yet carry “organic coffee”

 

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inside the department store n the main drag of Janakpur

 

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Saturday evening Hindu worship at Ganga Taal. This is popular. There are thirty lakes in the city limits. On the far of this one is the funeral ghats of the town.

Janaki Mandir

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in front of the Mandir is a plaza. They were televising a tent meeting the week I was there.

The centerpiece of the town is the Janaki Mandir.

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my cousin read this blog and she asked as to the significance of the pink cow. My reply? *what* pink cow? I don’t see a pink cow!”

Puja Supplies

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a portable shop for textile puja items.

More puja supplies

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these are inexpensive.a staple of home puja altars in South Asia.

and more

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pujas supplies on the plaza of Janiki Mandir

Because of Ram and Sita, a love story, the temple is popular for weddings, and something that astounded me was the number of processions, usually at night, and always with – a brass band. Sometimes  two or three parades converged on the plaza at the same time – glorious chaos!

The Ram mandir is a stone’s throw away. The backside of the Ram Mandir is under construction:

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the backside of the Ram Mandir was under construction. There is an interior courtyard for Kali at this site, I’m told it’s quite a scene during Dasain. to the right, out of the picture, is a lassi shop and pan shop, well worth the visit.

Lassi

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I found the lassi place on my own accord, then I was told this is considered to be the best in the district. Mitho 6! The guy behind the steel counter is the pan saudji – i.e., betel nut. In my experience, betel nut is more popular in Terai.

Leaves for Pan

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Basket of leaves in the marketplace, arranged just so. I learned that this is how the pan sellers like them. When you buy pan, there is a ritual of how it is prepared at point of sale.

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a panoramic shot of the front of the temple, showing the plaza.

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I was in Janakpur to teach critical care skills, and taught five sessions with about 125 participants. (the pic shows just one of the groups…) I’ll do a separate blog on the actual teaching. Together we worked to strengthen critical care practice in a town serving about 600,000 people.

 

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My”token of Love” from Janakpur was a silk screen done in Maithili style (note the iconic eyes) depicting a wedding. I shall cherish this!

 

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Burn care in Nepal, an update August 2016


In January 2016, I  wrote a piece about burn care on my other blog, titled “Bride Burning” in Nepal and Burn Injuries.

Book cover professionally scanned, small pixel version

My first book told the story of my first trip to Nepal. I worked with burn victims in 2007. Half the book is devoted to that experience. Burn injury is a big problem in Low Income Countries.

https://sacramentofthegoddess.wordpress.com/2016/01/17/bride-burning-in-nepal-and-burn-injuries/

The blog focused on the prevalence of burn injuries and the gender imbalance among victims. I wanted western readers to learn about the issue.

(oh, and you can buy my book at https://www.amazon.com/Hospital-at-End-World/dp/1935514288?SubscriptionId=15HRV3AZSMPK0GXTY102&tag=amznsearch.ms.vs-20&linkCode=xm2&camp=2025&creative=165953&creativeASIN=1935514288 )

This summer in Nepal I had the serendipitous chance to teach my course at Kirtipur Hospital, home of the Nepal Burn Center.

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The hospital building is relatively new and still under construction. It serves a dual purpose, both as burn center and community hospital for the town.

Kirtipur is an ancient town in the Kathmandu valley, home of a large campus of T.U., and southwest of the center of the city, outside the ring road.

And below the photo is a video from a few years back that features Dr Shankar Rai, a reconstructive surgeon.

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The fabric of Kathmandu’s bus system shows a wrinkle near Kirtipur since it takes two changes to get up the hill. This is one of the ad hoc bus parks.

 

The hospital is presently administered by Kathmandu Model Hospital. They freed up thirty staff to attend the CCNEPal three-day course.

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the participants were a cross-section of hospital departments. Here, we’re about to do a demo of one of the scenarios of the course.

There is a wonderful nurse from Australia who is working through PHECT, named Tina Bryce McKay.

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Tina Bryce McKay is a nurse from Australia who works at Kirtipur via PHECT. Earlier in the summer she came to Pokhara to help me.

I did not think i would teach in Kathmandu Valley, but when the schedule changed and I got some time, Tina got me the invite to train staff at Kirtipur.

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Tina ( blue bandana) works to elevate the standards of staff training. Here she is, guiding a nurse through ecg analysis. Quite a bit of the class is devoted to elementary ecg and how to incorporate it into overall assessment. Any person who says ecg is not a cornerstone of critical care, does not know what they are talking about.

They gave me a tour of the place.

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panoramic view of post-surgery ward during morning rounds. the layout is a large open space with low walls. The screen is used when dressings are change during rounds.

close-up of dressing cart

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minor wounds will be examined at bedside and major ones go to “Theatre”

and another view:

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Family involvement

Here is the waiting area outside the HDU, where patients are admitted when they have the most extensive burns. In Nepal, the family is expected to be nearby. In many cases, they donate skin to the victim.

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just outside HDU. the gowns are used when visiting their loved one.

In the area where the HDU is, the Operating Theatre has a room designated specifically for grafting and debridement.

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preparing for a debridement procedure. this would be done under light anesthesia to decrease the pain involved.

The HDU is a highly specialized Intensive Care Unit. When extensive burns occur, the victim inhales hot gas and can burn the upper airway. Inhalation burns are extremely serious.

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panoramic view of HDU at Kirtipur. There were six burn victims that day. All required ventilatory support. All had suffered burns of greater than 60%

The percent of burns is an important point. For years it has been an axiom in Nepal that >60% burns is not survivable.

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The “HDU” at Kirtipur is the most active critical care unit for burn victims in Nepal.

The physical plant of the hospital is only part of the story. In this case, Dr Rai – the main doctor behind the establishment of the hospital – is also a faculty member of NAMS, the National Academy for Medical Science, the oldest site for Post-Graduate Medical Education in Nepal. Along with other surgeons from NAMS, they have built a nationwide network to educate for best practices in burn care. Course have been held in many regions of Nepal, and local educators have been trained. They work with Nepal Burn Society; with Interplast; and with ReSurge International.

Here is a video from only two years ago that updates Dr Rai since the earlier one above. It was made just as Nepal Burn Center was being built.

Another piece of the medical system needed for effective burn treatment is to have a skin donor bank. – http://setopati.net/society/1073/

The website for Kirtipur is http://www.nepalcleftandburncenter.org/

Training Courses

Comments

The hospital at Kirtipur serves a critical need in Nepal to upgrade the level of burn care. Their efforts go beyond the construction of a physical building – they are also creating a nationwide network for burn education and care. They partner with international NGOs to advance the practice. Burn  care is intense, and it’s inevitable that they will have staff turnover. They need to continue to train their staff, and I think they could benefit from partnering with NGOs that will send future nursing specialists in Burn ICU.

My own efforts to educate nurses and doctors in advanced life support have paralleled the approach adopted by the Nepal Burn Society,  I am  impressed by their success.

 

 

 

 

 

 

 

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CCNEPal report of critical care training August 13th 2016


Summary:

It was good.

More detail?

Original goal for summer 2016 was to teach as many sessions as possible, focus on areas of Nepal outside of Kathmandu Valley, while yet minimizing bus travel.

Each session is two or three days in length, and consists of a variety of short lectures and discussion punctuated by “megacode” – simulated critical situations requiring a team response and return demonstration of specific scenarios. Here is an example of how the group breaks into “megacode” activities:

(above video shows  how the class divides into five groups for practice of scenarios)

At each location, I was humbled by the hospitality, support and enthusiasm of my hosts and the students.

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Dr Umid Shrestha of Pokhara is a faculty member of Manipal College of Medicine and a supporter of upgrading the nurses role in critical care in Nepal. He has supported CCNEPal from day one.

 

The means of deciding where to go was the same as in in past years. I announce my dates of availability on FaceBook and people contact me. I see what can fit the schedule. I email individual places that were on the waitlist of previous years to remind them I’m coming back. And it happens. It was amazing to see that based on word-of-mouth, I could refill the schedule at a moment’s notice when something changed.  Every session but one was full – (there was one session for just five MBBS students in Biratnagar that fell on Eid).

Please note: If I return in 2017 I will again use FaceBook to announce the dates.

The list of venues was:

Pokhara:

Paschimanchal Community Hospital

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Tina Byrnes of “Phect” joined me in Pokhara to see my ing methods. She is a nurse frm OZ now working at Nepal Burn Center and I returned the favor by collaborating on a session later in the summer.

 

Charak Community Hospital

Bharatpur:

College of Medical Sciences

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The College of Medical Sciences Teaching Hospital in Bharatpur operates one of the busiest Emergency Rooms in Nepal. They first hosted me in 2011.

Pushpanjali Community Hospital

Janakpur

Janaki Medical College Teaching Hospital ((JMCTH)

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Janaki Mandir is a major Hindu site in Nepal. the BBC documentary “Last Train in Nepal” was filmed here.

Janaki Health Care Center and Research Center (JHCRC)

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Here is a BBC documentary from a few years back that portrays a fascinating view of life in this region of Nepal.

JHCRC was my host in Janakpur. They were at 100% occupancy while I was there.

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Dr Raman Mishra (L) was my main contact in Janakpur. He was educated in Varanasi and practiced in Chandigarh India prior to returning home to Janakpur last year. In this photo, he is beginning the day with rounds accompanied by his entourage.

Biratnagar

Nobel Medical College Teaching Hospital

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Nobel Medical College is a major complex and they provide comprehensive services including a cath lab

Nobel has  committed to the use on education, investing in equipment and a training hall.

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the main training hall at Nobel Medical College

Bharatpur

Chitwan Medical College

Kathmandu

Bir Hospital School of Nursing,

Norvic International Hospital, and

Nepal Burn and Cleft Palate Center in Kirtipur

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The “HDU” at Kirtipur is the most active critical car unit for burn victims in Nepal.

Total number of certificates awarded:

715 – including nurses, MBBS, Medical Officers, Health Assistants, and Nursing students.

Number of sessions:

24.  Most weeks I worked six days per week.

Travel days

six. Instead of staying in Kathmandu and going out-and-back, out-and-back, I did a circuit.The longest was from Biratnagar to Bharatpur.

Cumulative totals:

from previous years, 2170 participants in 70 sessions.

2170 + 715 = 2,885 participants.

70 = 24 = 94 sessions

Discussion

The fundamental challenge of acute care in Nepal right now is that the hospitals are installing critical care units but the nurses and junior doctors are not trained to conduct their activities at the skill level required.

Nurses do not read ecg. Nurses have a superficial knowledge of equipment such as bag-Valve-Mask devices or ventilators. The primary system of nursing education teaches “Functional Nursing” which is the antithesis of the critical thinking required to assess and evaluate nursing care to a critically ill person.

Junior doctors, likewise, are not given any kind of formal ecg class, nor do they do BLS or ACLS training. During the internship year they may be conducting the team response to a cardiac arrest but have never been trained as to the protocols in any practical way.

Overall cultural factors tend to work against interdisciplinary collaboration due to the perceived role of women.

This continues to be a gap in health professions education in Nepal. The overall education system is theory-based and there is no transition to the practical-based focus exemplified by BLS, ACLS and the like.

Future Directions

CCNEPal will continue to advocate for inclusion of BLS and ACLS-type training in undergraduate nursing schools, including PCL programs.

CCNEPal will endeavor when possible, to introduce these methods to faculty as well as critical practitioners.

CCNEPal will identify leaders who can teach this themselves.

CCNEPal will introduce the teaching methods and skills to as many medical colleges in Nepal as possible, and advocate for course placement in 4th year of MBBS or at start of Internship year after MBBS.

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quite a bit of the class is devoted to elementary ecg and how to incorporate it into overall assessment. Any person who says ecg is not a cornerstone of critical care, does not know what they are talking about.

CCNEPal will continue to share information about Nepal with medical and nursing schools in the west as well as with individual persons wishing to collaborate with Nepali health care organizations.

 

 

 

 

 

 

 

 

 

 

 

 

 

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The Siren Song of Global Health electives in Nepal July 2016


The siren song of Global Health in Nepal

this is for my USA readers. Most of the time I comment on events here in Nepal it’s directed to a Nepali audience. Not this time.

In USA these days the wish to include a Global Health experience into education is stronger than ever. For medicine, nursing, public health, and other specialties, the college or University graduate programs are testing the waters for clinical placements of various kinds. Nepal has always been an adventuresome choice for brave souls, and Nepal has a mystique about it that beckons.

Expanding the menu

The vast majority of North Americans go to just one or two locales in Nepal for an elective, and these are getting crowded. The magic gets diluted when it becomes a stop on the international trail. For example, one of the more popular places is now hosting up to a hundred foreigners at any given time. This changes the nature of the experience. A related question is “With twenty medical colleges in Nepal, why is it that only two or three become the hosts of the foreigners?”

Serving as a resource

At the spring 2016 meeting of the Consortium of Universities for Global Health, I met many people who asked if I’d share contact information at all the places I go, and give advice as to what medical services were offered. So I plan to compile a sort of offbeat guidebook to the  hospitals and schools with which I interface.

I’ll include photos, a description of the geographical location, pics of the buildings, and contact information of key people at each place.

Travel agency?

Um, no. I’m not a booking agency. I think there are many different levels in which a professional person can participate in global health. My audience for this would be people with bonafide credentials that wish to gain perspective. This is not ” trekking with toothbrushes”nor is it volunteering at an orphanage or teaching English to Tibetan exiles. Those are worthwhile for some people, but not related to what I do when I am here.

So be on the lookout. If you have questions, send me an email.

 

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July 21st report for the summer and upcoming schedule


I’m back in Bharatpur, where I was a month ago. The return bus ride through eastern Terai was wonderful – like riding through The Shire.

Statistics to date:

As of today I taught 19 sessions, with 560 certificates awarded.  The present plan is to teach five more sessions, with possibly 150 more certificates – if that works out it will mean I trained 710 nurses, doctors and others, this summer. On the FB page, I made a photo album that consists of one group picture for each batch.

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It is a large number of people, and the goal has been to introduce the idea of ACLS as widely as possible.

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The schedule?

July 24th, 25th, and 26th – Chitwan Medical College staff nurses.

July 27th, 28th and 29th – Chitwan Medical College B Sc Nursing students

July 30th – travel to Kathmandu via bus. should be the final bus trip of summer 2016. Hooray!

July 31st, Aug 1st Aug 2nd – BN students at a school of nursing in Kathmandu.

August 3rd, 4th, 5th – Norvic Hospital, Thapathali

August 6th, 7th and 8th – possibly a hospital in southern Kathmandu Valley.

August 11th – return to USA.

It’s been a productive summer and I have brought the info to new places. I previously taught 2,170 people, the grand total will now bump up to 2,880 if the plan holds up. Many thanks to all who made it possible.

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Ten Rules to Prevent Thrashing of Doctors in Nepal


When a patient dies, the doctor is often blamed, and the family is angry. Thrashing the doctor is is a problem throughout Nepal. I made this list for my most recent sessions of Critical Care Class. The reality is, we are all going to die, and when we do, there is nobody to “blame.” It is not the doctors fault.
Communication is the key
Effective resuscitation more than just the ecg, BLS and drug protocols. The leader of the team must manage the interactions with patient party, and also with administration and police if things do not go well.
The Leader of the resuscitation team must recognize that the team is not just the other doctors and nurses, but also the guards and sometimes the police. It is not enough to only focus on resuscitation. Also, in previous blogs I have given link to checklist for secure building.
1) Goals The goals of resuscitation are always:

a) conduct the most effective resuscitation effort possible,

b) allow family to express emotion, ‎and

c) keep all parties safe from harm.

2) Weapons if any patient party shows a weapon, run away. You are never being asked to sacrifice your own life for doing this work.
3) Access limit access to emergency room or ICU asap when critical ‎situation develops. All exits and entrances must be guarded or secured.
4) Security Guards communicate with chowkid‎ars. This is two-way. Chowkidars serve as eyes and ears beyo‎nd the ER door. If patient party outside is upset, they alert staff. If staff is having problem, guards are notified. If problem develops, chowkidar sends for extra help. If ER doctor directs doors to be shut, immediate limitation of traffic must take place.
 
5) Police pre-enter phone numbers of administrators and prahari into all smart phones. If a situation gets out of hand you do not want to be looking up the number. For that matter, invite the local police to the ER on a quiet day so you will know each other.
6‎) Counseling send staff person to sit with anxious relatives. Staff person assesses education level and directs teaching to most educated person present. 
7) Chairs give patient party opportunity to sit. (‎more difficult to get physical).

8) period of respect after death if death occurs, ALWAYS wait fifteen minutes before allowing family to view the body so that remains will no longer be “twitching” – this is very upsetting and confusing to many persons.

9) mutual support doctor brings a nurse and chowkidars when counseling patient party.

10) Tone of voice pay strict attention to tone of voice of staff at all times. Apply principles of “de-escalation” whenever tone starts to escalate.

This blog has given ample advice on this subject, browse past entries to learn more.

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June 6th update as to schedule


Update
CCNEPal has completed the sessions in Pokhara.
I loved meeting all the people there. Dr. Umid Shrestha of Paschimanchal Community Hospital and Matron Sushila Neupane of Charak Memorial Hospital were wonderful hosts. ‎ I thank them. They are visionaries for the future of critical care in Pokhara.
I gained much appreciation for the level of skill to be found among the interns and medical officers from Manipal College of Medicine.
I think the ICU at Charak Hospital is every bit as well-organized as any ICU in the Kathmandu Valley. An ICU is measured by the skill of the nurses, not by the equipment list.
Students in the nursing sessions came from PCH; Fishtail Hospital; Fewa City Hospital; Western Regional Hospital; and  Gandaki Medical College as well as from Baglung, Damauli, and Gorkha.  I was joined for one session by Tina Byrnes, RN from Sydney who is conducting a nursing project in Kirtipur under the aegis of PHECT, an Ozzie quasi-governmental entity.  I think I gave her a few ideas.
I did not previously know there was a “New Road” in Pokhara. ‎
Bharatpur, College of Medical Sciences
June 4th was a bus trip to Bharatpur for the next leg of the journey. I’m trying to minimize bus travel.
I got to the tourist bus station okay and used the toilet there. Normally I wouldn’t add such a detail, but the electricity was off and the toilet was pitch black dark. Not even one photon. Ever try to use an unfamiliar bathroom in the dark? I didn’t want to use my smartphone flashlight for fear of dropping it in ” the hole”.   In the process of getting my trousers back up, my wallet slipped from my pants pocket. I ran back for it when I noticed it missing, almost left it behind. I do a lot of “check twice, you’re not coming back here again” when I travel, glad to have developed the habit of patting myself down.‎
From Pokhara to Mugling the road travels through a scenic region that evokes “The Shire.” Looking out the bus window was a travelog of village life in the hills – verdant fields, people tending to tasks of daily life. The road between Mugling and Narayangarh was a mess, due to a widening project. Many stretches of one-lane road. The drivers were patient with each other. ‎ It will be great when it’s done. Just not now. The Nepali method of road widening seems to always start with demolishing the previous road. ‎ This is the road that hangs on the steep side of  a river gorge. There are places where it seems like the engineers just flung it up there to see if it would stick.
 We’ll have three sessions of the course here at CMS.
June 5, 6, 7 – 4th-year B Sc nursing students. (thirty)
June 8, 9,  – MBBS/interns. (twenty)
June 12, 13, 14 – 3rd-year B Sc nursing‎ students. (thirty)
My contact person here is Mrs. Sita Parajuli, Matron of the Hospital and Campus Chief.  Sita Ma’am was in Tansen for many years, so even before I met her here in 2011 we shared many mutual friends.  Sita Ma’am has advanced nursing in the Terai. Due to the education system here, CMS faces turnover among the nursing staff. Young PCL graduates stay two years then go for their BN degree (this system is being changed because of this very problem). Sita is always growing the leaders and the staff.
June 15th, 16th and 17th are open dates. I’ve been asked to work with one of the small hospitals here, this is not confirmed.  If I do, I’ll post it for possible students to join, who may be otherwise unafilliated.
Janakpur?
June 18th I leave for Janakpur, home to the famous temple. I am told they are starting up an ICU in that city. The time is just flying by.
Kathmandu?
I’ve gotten inquiries about Kathmandu sessions. There are none planned. I’ve spent ample time in Kathmandu in the past. About 800 nurses and doctors there got my training.  Sure, there is demand for more, but Kathmandu has many people who could be teaching this.
A comment about mission of CCNEPal
CCNEPal’s goal is to promote critical care skills using a training method exemplified by the BLS and ACLS courses of the American Heart Association (AHA) in USA. We are emphatically *not* part of AHA, and this course does *not* lead to AHA certification. Due to AHA’s impeccable and authoritative  scientific research about resuscitation, we do teach the AHA standard when we can – adapted to the needs of Nepal. Participants learn in Nepali language. You do not need to be expert English speaker to benefit from this training.
It has been obvious from the beginning that we need to teach “what ACLS is” before we can teach how to do it. That is why we offer our sessions to the largest number of nurses and doctors possible. We are trying to create a medical culture shift that recognizes ‎the need for trained nurses in critical care.
What is “sustainable?”
A couple of years ago, I met a USA doctor from a famous USA medical center who told me what I was doing was “not sustainable.” In the meantime, that same doctor trained about a dozen people in her sub-specialty. ‎ It will be ten years before the training she did will come into general knowledge. That was a drop in the bucket considering that Nepal has thirty million people. By comparison, CCNEPal has trained 2,300 as of this year, and many of them used their new skills on April 25th, 2015. The nurses and doctors who need this knowledge are the young ones at the beginning of their careers, now working directly with patients. Persons who come to Nepal to train need to find a way to reach a broad audience, and not limit it to the senior doctors doing mainly administrative work.  “Train the trainer” is more difficult to do and implement that some might think.  I ten words or less: what I do is more “sustainable” than what that other person was doing.
If you are a foreign medical personnel thinking of coming here to train, you are invite to browse this blog.
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