Medical Volunteers are urgently needed now in Nepal Jun 24th 2015


Disaster relief drama

The April 25th earthquake provoked an international response from countries all over the world. Everyone knew that Kathmandu was overdue for an earthquake, and planning had taken place quietly. The western countries responded with a huge airlift. Hundreds of teams of foreign search-and-rescue teams came, as well as specialized groups of urban rescue dog handlers, looking for bodies in the rubble. Major NGOs arrived with supplies of all kinds. It wasn’t perfect but it was impressive.

Along with all these people came the international press. The news people were looking for total devastation such as took place in Port-au-Prince Haiti in 2010 where 100,000 people died. Sanjay Gupta, a celebrity doctor, did brain surgery at Bir Hospital. The media from India went on every helicopter, crowding out the victims who also needed those same rescue flights.

Journalist job number one: report what you see, not what the people want to see

But this particular earthquake had a flavor all it’s own, and after a few days some of the local journalists wrote about the hype from international media.  Yes, the were fatalities. Almost ten thousand. Yes, the major monuments were affected. But the vast majority of casualties were in the rural areas – this is a very rural country, eighty percent of people live in small towns and villages. The response after the initial period was more focused on the logistics of reaching people in roadless areas. Not anywhere near as dramatic. There were many examples of Nepali people who mounted their own do-it-yourself relief operations, which was amazing and awakened a sense of national pride that seemed to be dormant.

I was in the country at the time of the quake, though not in Kathmandu. That very day my blog started to receive hits on the entries inviting nurses to volunteer here. For a while I was getting 800 hits a day. My advice? don’t come. You’ll get in the way.

I still think it’s important for nurses and doctors to prepare as much as possible before making a trip here. But my advice has now changed. Yes, do come.

For your first trip to the country, my advice is to join a group and go on a trek if you are able. This suggestion may surprise you; if you are an acute-care adrenaline junkie you may have the idea of doing brain surgery on day one, like Sanjay Gupta did.

Um, hate to break it to you, but – Esteemed celebrity Doctor Gupta is not the role model you should emulate. You may be surprised to find that nurses and doctors in Nepal are pretty smart and well-trained in many ways. (and, you need a Nepali license to practice, here.)

I myself used to not respect  the so-called “medical treks” offered by some tour groups. Why? because the medical component was not “hard core.” For example, there was one group run by a nurse from USA who also was a marathon runner. They did 15 miles a day – a forced march for those who might not be in the best fitness. The trek they offered  was billed as a medical tour but they never  visited a hospital, for example, or met with any local nurses or doctors until I gave them some contact names. The medical part boiled down to handing out toothbrushes and sample packs of antibiotics as they hiked through villages. This approach creates “dependency” among the people served by the trekkers. Likewise, I used to wonder when I saw such groups as Habitat for Humanity, bringing westerners to Nepal to build houses. Nepali people are perfectly capable to build their own shelter, thank you very much.

I am modifying my attitude. I think that anything to get Americans/Europeans/westerners out of their comfort zone and travel is good. And I re-evaluate Habit for Humanity. Habitat for Humanity, for example, is not just about carpentry – it’s about having a cultural exchange under the umbrella of leaving something behind that is tangible. AHA! Now I get it.

Having said that, you do need to choose a tour group or trek wisely. More on that later.

Adventure Travel? group tour? beach vacation?

People have different styles of travel, and if the only way they can step out and explore the planet is to go with a group, that is what they should do. (warning: if your travel style focuses on taking small kids to the beach, you will be disappointed. Nepal is eight hundred miles from the ocean)

When I returned to the Kathmandu Valley in late May, just before my year in Nepal was up, the first thing I noticed was that most of it was intact. The main missing ingredient was the tourists. How can this help recovery? I asked myself. The obvious answer was, if tourists stay away, recovery will be delayed. And so I am joining those who are saying, now is a great time to visit Nepal.

What’s there and what’s not

if you go, you will still find friendly people, an amazing local culture, and breathtaking scenery. You will meet a wide cross-section of locals – from highly cosmopolitan citizens to members of ethnic groups that live off the land much as people did four hundred years ago. The cultural and spiritual opportunities are life-changing. you won’t be the same person.

What’s  not there are – some of the monuments. Frankly, the majority of tourists would do a whirlwind tour of the monuments but not stop to savor each one. The culture surrounding the monuments is undamaged. Buddhist, Hindu, Tibetan, Newari – the people are still celebrating festivals and life events.

Using your skills

Yes, I am saying Go there first just to trek. You will fall in love. The rest of your contribution, from a medical viewpoint, can be meaningful and important. But you will do better if you stop and smell the incense.

The Bottom line

There are many ways a foreign medical person can contribute in Nepal, and I invite you to study the 150 previous entries in this blog  to find examples. if In a future blog I will give my specific list of suggested ways you can help medical development in Nepal, as well a some specific Non-governmental organizations (NGOs) that might work with you.

 

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Disaster Competence Literature review part 2 Ethical Issues by Gaynor Sheahan


editor’s note: part two of a review of disaster nursing by Gaynor Sheahan, RN, MS This is from a paper written for Monash University. reprinted with permission.

Ethical Issues in Disaster Nursing

Ethical issues and cultural competence are also significant issues considered important for inclusion in core competencies. Scarce resources in a disaster mean that nurses must make difficult choices, with the greater good of the many taking priority over the benefit of the individual, a foreign concept often for many nurses without disaster experience (International Council of Nurses, 2009). The ICN also highlights the need for nurses to be aware of such ethical dilemmas, and the importance of cultural competence (respect, dignity and knowledge of cultural norms) an important feature of any disaster education.

Code of Ethics? 

Karen Schroeter (2008) questioned whether the American Association of Nurses Code of Ethics applies in the same way during a disaster. Examples include: if a nurse should decide to evacuate along with their family; should a nurse be held accountable for their actions during a disaster; whether nurses can provide adequate care when supplies are gone; the reuse of supplies which would under normal circumstances be discarded; the refusal to care for patients if so doing might impact their own families; lack of personal protection equipment; provision of partial care due to scarce resources despite negative outcomes.

Triage

Ethical dilemmas of disaster triage pose particular problems due to limited resources and the large numbers of patients presenting during a disaster. A particular ethical dilemma is whether treatment priority should be given to frontline workers or their families to enable disaster workers to work more effectively (Schroeter, 2008).  The decision to evacuate families of key response workers first during Cyclone Tracy in Darwin in 1974 resulted in less distraction for the workers by worry about the care of their families, and in improved outcomes for the community (Fitzgerald, Aitken, Davis, & Daily, 2010).

This conflict between personal and professional obligations in a disaster is an important issue. Mary Caffee has made a comprehensive assessment on how to reconcile these conflicting obligations when making the decision to report to work in a disaster, with steps to be taken by both the nurse and the institution as part of disaster preparation (Chaffee, 2006). Schroeter (2008) concludes that every nurse should know their own personal line for professional integrity, and have some understanding of their own duty of care during a disaster when conditions are likely to be unsafe, advising nurses to decide before a disaster the level of risk they are prepared to accept, in consultation with colleagues and family.

A distinction has also been made between the ability to respond and the actual willingness to respond in a disaster (Qureshi et al., 2005). The most common inhibitors to respond in this study were transportation, obligations towards care of children and older family members, and personal health concerns. Fear and concern for family and self were the most frequently given reasons for actual willingness or personal decision (as opposed to ability) to respond.  The HCW is thus determining their personal ethical approach to a disaster response and assessing risk, prioritizing whether personal welfare or that of their family is more important than that of the community (Qureshi et al., 2005).

These findings were echoed by Australian research in the first phase of a national survey conducted of 450 Australian nurses from four different hospitals, into willingness to respond in a disaster (Arbon et al., 2011). The major concerns related to the nurses’ own personal safety or that of their families, with domestic living arrangements and elderly or disabled dependants significant factors influencing willingness to respond. Lack of knowledge or clinical confidence has also been suggested as an important factor involved in failure to respond in a disaster (International Council of Nurses, 2009).

The type of disaster would also seem to affect whether a HCW would respond or not according to the study by Qureshsi et al  (2005). Eighty-three percent of HCWs would respond to a mass casualty incident, 81% to an environmental disaster, and 71% to a chemical event, but least able to respond where personal or family risk was perceived to be high: smallpox epidemic (69%), radiological event (64%), sudden acute respiratory distress syndrome outbreak (64%). Of Australian nurses, 30% were unwilling to respond to a chemical or biochemical event, and were most likely to attend to natural disasters, pandemics, and terrorist attacks (Arbon et al., 2011).

Interventions such as a family emergency plan to ensure family will be cared for (Arbon et al., 2011; Gebbie & Qureshi, 2006; International Council of Nurses, 2009), and priority evacuation of the families of HCW if necessary such as happened in Cyclone Tracy may increase the likelihood that a HCW will respond in a disaster, with benefits for the entire community (Fitzgerald et al., 2010). Other issues could be addressed with appropriate planning and preparation, such as transportation solutions, personal protection equipment, environmental controls, and ensuring personal medication supply if needed (Qureshi et al., 2005).

Nurses need to be involved in disaster planning and preparation to ensure ethical considerations are taken into account (Schroeter, 2008) and it could be argued that  ability to respond and willingness to respond are as important as ethics and core competencies when considering disaster education and preparedness. Strangeland (2010) noted that 40% of HCWs in the studies she examined would not respond in a disaster and suggested that more research was needed in order to more fully understand nurses’ intent to respond to disasters, and their reasons for not responding, as the capacity of hospitals to cope in a disaster is directly related to nurse staffing levels.

In conclusion, many questions remain concerning core competencies in disaster education for nurses. A lack of consensus in regard to the clinical skills, knowledge, abilities, ethical framework, and scope of practice, is reflected in the number and variety of core competences developed by a myriad of organisations and countries, unsupported by universal terminology. The optimal timing for disaster education, evaluation of the effectiveness of core competencies in relation to improved outcomes in a disaster, as well as the financial cost involved, especially for developing countries, is yet to be addressed fully. There is little literature to identify the necessary qualifications and experience of nurses attending disasters, their scope of practice, and the most effective nurse-patient ratios (International Council of Nurses, 2009). Little research exists addressing whether current training is effective and achieves competency aims, with few research tools having been established in the field of disaster health (Lynn Slepski, 2007). The ability and willingness of nurses to respond in a disaster are also issues that need further research (Strangeland, 2010). Empirical evidence supporting disaster nursing is lacking due to the difficulties involved in conducting research under disaster conditions (Veenema, 2007). This lack of empirical data could be overcome by further studies based on health professionals with previous or current experience of disaster health (Daily et al., 2010) to assist identification of the critical issues in disaster health, and from that, establishment of a common framework for competencies. (See Appendix 3)

REFERENCES 

Arbon, P., Cusack, L., Ranse, J., Shaban, R., Considine, J., Mitchell, B., . . . Bahnisch, L. (2011). Understanding the willingness of Australian emergency nurses to respond to a disaster. Adelaide, Australia: Flinders University.

Asian Disaster Reduction Centre. (2011). Natural Disasters Data Book 2011: An analytic overview Retrieved 11th September, 2012, from http://www.adrc.asia/publications/databook/DB2011_e.html

Chaffee, M. (2006). Disaster Care: Making the decision to report to work in a disaster. American Journal of Nursing, 106(9), 54 – 57.

Chapman, K., & Arbon, P. (2008). Are nurses ready? Disaster preparedness in the acute setting. Australasian Emergency Nursing Journal, 11, 135-144.

Daily, E., Padjen, P., & Birnbaum, M. (2010). A Review of Competencies Developed for Disaster Healthcare Providers: Limitations of Current Processes and Applicability. Prehospital and Disaster Medicine, 25(5), 387-395.

Fitzgerald, G., Aitken, P., Davis, E., & Daily, E. (2010). Disaster Recover. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

Gebbie, K., & Qureshi, K. (2002). Emergency and Disaster Preparedness. American Journal of Nursing, 102(1), 46-51.

Gebbie, K., & Qureshi, K. (2006). A Historical Challenge: Nurses and Emergencies. The Online Journal of Issues in Nursing, 11(3).

Hein, K. (2010). The Competency of Competencies. Prehospital and Disaster Medicine, 25(5), 396-397.

Hsu, E. B., W, J. M., Catlett, C. L., Robinson, K. L., Feuerstein, C., Cosgrove, S. E., . . . Bass, E. B. (2004). Effectiveness of hospital staff mass-casualty incident training methods: a systematic literature review. Prehospital & Disaster Medicine, 19(3), 191-199.

International Council of Nurses. (2009). International Council of Nurses Framework of Disaster Nursing Competencies (W. P. Region, Trans.): World Health Organisation.

Jennings-Sanders, A. (2004). Teaching disaster nursing by utilizing the Jennings Disaster Nursing Management Model. Nurse Education in Practice, 4, 69-76.

Jennings-Sanders, A., Frisch, N., & Wing, S. (2005). Nursing Students’ Perceptions About Disaster Nursing. Disaster Management & Response, 3(3), 80-85.

Kako, M., & Mitani, S. (2010). A literature review of disaster nursing competencies in Japanes nursing journals. Science Direct, 17, 161-173.

Kelen, G., & Sauer, L. (2008). Trend analysis of disaster health articles in peer-reviewed publications pre- and post 9/11. American Journal of Disaster Medicine 3(6), 369 – 376.

Kingma, M. (2010). Foreword II. In R. Powers & E. Daily (Eds.), Introduction to Disasters and Disaster Nursing. New York, United States of America: Cambridge University Press.

Landesman, L. (2001). Public Health management of disasters: the practice guide 2001. Washington DC, USA: American Public Health Association.

McMahon, M. M. (2010). Hospital Impact: Emergency Department. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

Nair, M., & Webster, P. (2010). Education for health professionals in the emerging market economies: a literature review. Medical Education, 44, 856-863.

Qureshi, K., Gershon, R. R. M., Sherman, M. F., Straub, T., Gebbie, E., McCollum, M., . . . Morse, S. S. (2005). Health Care Workers’ Ability and Willingness to Report to Duty During Catastrophic Disasters. Journal of Urban Health, 82(3), 378-388.

Ranse, J., Arbon, P., Ramon, S., Considine, J., Mitchell, B., & Lenson, S. (2010). Exploring the disaster content in Australian postgraduate emergency nursing programs Retrieved October 5th, 2012, from http://www.jamieranse.com/2010/10/exploring-disaster-content-in.html

Regmi, K. (2008). Adult learning opportunities in Nepal. Journal of Adult and Continuing Education, 14(1), 85-94.

Regmi, K., Regmi, S., & Shahi, M. (2009). Tibhuvan University certificate nursing curriculum. Journal of Institute of Medicine, 31(3).

Schroeter, K. (2008). Nurses, Ethics, and Times of Disaster. Perioperative Nursing Clinics, 3, 245-251.

Slepski, L. (2007). Emergency Preparedness and Professional Competency Among Health Care Providers During Hurricanes Katrina and Rita: Pilot Study Results. Disaster Management and Response, 5(4), 99-110.

Slepski, L., & Littleton-Kearney, M. (2010). Disaster Nursing Educational Competencies. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

Stanley, J. M., & Veenema, T. G. (2007). Directions for Nursing Education. In T. G. Veenema (Ed.), Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards (Second ed., pp. 545-554). New York, United States of America: Springer Publishing Company.

Strangeland, P. A. (2010). Disaster Nursing: A Retrospective Review. Critical Care Nursing Clinics of North America, 22(4), 421-436.

University of Hyogo. (2006). Core competencies Required for Disaster Nursing Retrieved September 14th, 2012, from http://www.coe-cnas.jp/english/group_education/core_competencies_list.html

Usher, K., & Mayner, L. (2011). Disaster nursing: A descriptive survey of Australian undergraduate nursing curricula Australasian Emergency Nursing Journal 14, 75-80.

Veenema, T. G. (Ed.). (2007). Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards (Second ed.). New York, United States of America: Springer Publishing Company.

Wynd, C. A. (2006). A Proposed Model for Military Disaster Nursing. Online Journal of Issues in Nursing, 11(3).

Yin, H., He, H., Arbon, P., & Jingei, Z. (2011). A survey of the practice of nurses’ skills in Wenchuan earthquake disaster sited: implications for disaster training. Journal of Advanced Nursing 

Appendix 1:  

Yin, H., He, H., Arbon, P., & Jingei, Z. (2011). A survey of the practice of nurses’ skills in Wenchuan earthquake disaster sited: implications for disaster training. Journal of Advanced Nursing.

 Essential skills for core competencies
1.      First aid

2.      Basic life support

3.      Advanced cardiac life support

4.      Infection control

5.      Field triage

 Additional Skills
1.      Mass casualty transportation

2.      Emergency management

3.      Haemostasis,

4.      Bandaging

5.      Fixation

6.      Manual handling

7.      Observation

8.      Monitoring

9.      Mass casualty triage

10.  Controlling specific infection

11.  Psychological crisis intervention

12.  Cardiopulmonary resuscitation

13.  Debridement

14.  Dressings

15.  Central venous catheter insertion

16.  Patient care recording

 

 Appendix 2:

 

McMahon, M. M. (2010, p89). Hospital Impact: Emergency Department. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

 Criteria for non-ED staff caring for patients in ED

during a disaster

1.      Rapid assessment

2.      Advanced Cardiac Life Support

3.      Airway management

4.      Intravenous access skills

5.      Resuscitation & stabilization

6.      Managing several critically injured/ill patients simultaneously

7.      Critical thinking

8.      Knowledge of disaster principles and Incident Command

9.      Ability to function independently

 

Appendix 3:

Daily, E., Padjen, P., & Birnbaum, M. (2010). A Review of Competencies Developed for Disaster Healthcare Providers: Limitations of Current Processes and Applicability. Prehospital and Disaster Medicine, 25(5), 387-395.

 

 Suggestions for future research
·         Collect information from all disaster responders post event to identify competencies for job roles and establish framework for competency modeling

·         Agreement on terminology

·         Precise, well articulated competency statements to enable consistency, proper assessment and standardized education

·         Regulatory bodies to set standards for practice certification and accreditation for educational programmes

·         Inclusion of input from international communities to promote more universally applicable and adaptable competencies

 

 

 

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Disaster Competence Literature Review Guest Post by Gaynor Sheahan RN, M Sc June 8 2015


Editor’s note: Gaynor Sheahan, RN is a nurse from Australia with long ties to Nepal, including work at Patan Hospital to set up their first triage system. She wrote this paper about disaster nursing as a graduate school assignment. It is reprinted here with permission, in two parts ( part two will be added in a day or two). I formatted the bolded headers as a means of making it easier on the eyes.

Assessment Task 3:

Review the literature and discuss the competing issues of competencies, expanded scope of practice, ethical practice and the ability to respond.

Attention towards identifying core competencies in disaster nursing intensified following what is now commonly called 9/11 in the USA in 2001 (Daily, Padjen, & Birnbaum, 2010; Gebbie & Qureshi, 2006; Veenema, 2007). The 2002 Bali bombing, in which many Australians were killed or injured, could be said to be the Australian equivalent of 9/11. The 24-hour news cycle and the speed with which news (and images) of disasters now travel around the world via the Internet, has increased awareness and, one could argue, fear of the likelihood of disaster striking closer to home than might have been perceived in the past.  “A new level of urgency” has been described in teaching disaster nursing (Jennings-Sanders, 2004, p. 69) and heightened concerns about disaster events is evident amongst health care workers (HCWs) in recent years (Chapman & Arbon, 2008). An increase is also evident in the number of generalist as well as disaster specific peer reviewed journals publishing disaster health related material (Kelen & Sauer, 2008). The impact of disasters in humanitarian terms and on health care systems is immense and likely to worsen due to numerous factors including climate change, unplanned urban expansion, and technological events, with the risks worse for poorer populations. Yet according to Wynd (2006) there are few disaster nursing models with a global perspective, and the International Council of Nurses (ICN) states, “The global nature of disasters makes it imperative that nurses are equipped with similar competencies in order to work together in providing for the health needs of disaster populations” (2009, p. 15).

Defining Competence

In this essay competence will be defined, and the difficulties of including within core competencies a myriad of skills and knowledge based competencies such as clinical task-based skills, personal abilities or attitudes such as creative thinking, and disaster specific knowledge. Research that there are too many core competencies, too much complexity, and confusion as a result of varying terminology will also be considered, and whether core competencies have been effectively evaluated in relation to disaster outcomes. The optimal timing and capacity for teaching core competencies is also an important factor when examining disaster education. The financial cost of disaster education to equip nurses with core competencies, especially in developing countries, will also be discussed. The ethical framework and scope of practice in relation to core competencies will be discussed, with the ability or willingness of nurses to respond in a disaster having an important impact on disaster outcomes, perhaps regardless of core competencies.

Components of Disaster Competence

Competence is described as an integration of knowledge, skill and judgment, with five main areas of competence: professional development; care management in disaster situations; care provision for vulnerable people and their families; systematic assessment and provision of disaster nursing care; fundamental attitudes towards disaster nursing (International Council of Nurses, 2009; University of Hyogo, 2006). Yet few nurses have disaster experience and most are inadequately prepared, especially in terms of workload, prioritizing patients, and using limited resources appropriately (International Council of Nurses, 2009; Jennings-Sanders, 2004).

 Although the need for universal core competencies for disaster nursing is generally accepted, the research reflects the difficulties in identifying essential competencies and the necessary scope of these for generalist nurses. Disasters cover a range of situations: from earthquakes to tsunamis, from bombings to stampedes, from fires to biological or chemical accidents, from floods to random multiple shootings by one assailant. No two disasters can be considered the same (Landesman, 2001). One of the first research articles into core competencies suggested that trigger events for disasters can be difficult to anticipate and to prepare for, yet preparation through attainment of core competencies is vitally important (Gebbie & Qureshi, 2002).

Some have argued that in order to respond effectively, nurses need to have the same core competencies regardless of the type of disaster (Gebbie & Qureshi, 2002), and that it is unrealistic to expect nurses to be clinically skilled for all specific disaster conditions, recommending “just in time training” for less common specific injuries and illnesses (Gebbie & Qureshi, 2006, p. 6). A military model of nursing has been suggested, applicable to both military and civilian types of disasters, since military nurses already have many of the competencies required for a disaster situation such as setting up field hospitals and coping with large numbers of casualties (Wynd, 2006).

Specific Skills Needed

A commonly held perception is that critical care or emergency nurses, competent in clinical task based skills, are more appropriate HCWs in a disaster. The ICN (2009) acknowledges the need for generalist nurses to have basic skills such as airway, breathing, and circulation assessment skills, and management of pain, burns, hypovolaemia, fractures, crush injuries and other traumatic emergencies. Five essential clinical skills were identified in a small study following the Wenchuan earthquake in China with a larger skill list of 16 suggested as important to be included in disaster education (Yin, He, Arbon, & Jingei, 2011) (See Appendix 1). A pilot study of healthcare responders involved in Hurricane Katrina and Rita, found that not only were basic clinical care and triage the most commonly used skills but were also the skills responders felt least prepared to use (Lynn Slepski, 2007).

Nurses were the preferred first responders according to the Wenchuan earthquake study, with the following optimal qualifications: emergency rescue training or emergency department experience, and with at least three years clinical experience (Yin et al., 2011). The criteria for non-emergency trained staff caring for patients during a disaster has been summarised as a largely clinical skill based list (1 – 5) but with some personal competencies included (5 – 9) (McMahon, 2010, p. 89).  (See Appendix 2)

The question of the optimal balance between including clinical task-based skills, as well as personal abilities or attitudes, and disaster specific knowledge in core competencies is raised in the research. A comprehensive set of core competencies for disaster nursing developed following the terrorist attacks in USA in 2001 covered not only specific practical skills, but also specific disaster relevant knowledge competencies (Gebbie & Qureshi, 2002). Some have argued however that too great an emphasis has been put on clinical role competencies at the expense of personal competencies (Daily et al., 2010). Gebbie & Qureshi (2006) suggested that it was necessary for a “balance between knowledge of how emergency response works as a system, in contrast with knowledge of signs, symptoms, and clinical management of the injuries and illnesses caused by the many specific agents of disasters” (Gebbie & Qureshi, 2006, p. 9). Tener Goodwin Veenema highlights the need to provide nurses with both “a solid foundation of knowledge (educational competencies) and a toolbox of skills (occupational competencies) to respond in a timely and appropriate manner” in a disaster situation (Veenema, 2007, p. v).

Characteristics of Nepali educational system that inhibit development of competence

Creative problem solving, flexible thinking, communication skills, and ability to evaluate effectiveness have also been recommended as core competencies (Gebbie & Qureshi, 2002, pp. 49-50; Stanley & Veenema, 2007). However, core competencies such as these may be difficult to foster in developing countries. Nepali nurses for example, have often experienced only a rote learning, didactic, teacher led educational system prior to entering nursing school (Regmi, 2008), and generally follow set routines and procedures with a task orientated focus. Critical thinking and problem-solving skills are not well developed (Regmi, Regmi, & Shahi, 2009). This is not uncommon in developing countries, where there is often an outdated nursing curriculum and teaching methods, a shortage of nurse educators, and the need for a standardized accreditation system (Nair & Webster, 2010).

 It has been suggested that core competencies in disaster nursing may be too complex, too numerous, and that the lack of standardized terminology impedes comparison for best practice. A literature review of disaster nursing competencies in forty three Japanese nursing journals, concluded it was difficult to provide an overview due to the wide definitions of competencies, with disaster nursing itself covering a broad area, and competencies largely focused on the acute phase of a disaster, and less so on other phases such as recovery (Kako & Mitani, 2010). Elaine Daily (2009) is cited in the same article as stating that there exists a “complexity of competencies” due to the numerous agencies involved in a disaster event, with no commonly accepted standard of education (Kako & Mitani, 2010, p. 11). In addition, the review suggested too many competencies, with various organisations creating their own competencies.

Similarly, Daily, Padjen and Birnbaum (2010) evaluated commonalities and their universal applicability in their review of published disaster health competencies, and discovered hundreds had been developed by a variety of organisations, including governments. Comparison was made difficult by imprecise and inconsistent terminology, and use of various terms such as competency, domain and sub-competency. In 2010, Karen Kein commented that humanitarian professionals working in disaster health “do not know what they do not know. Much of the education and training remains outdated” with no agreement on domains or specific core competencies for response and preparedness (Hein, 2010, p. 396).

Education and training programmes are key to effective disaster preparedness, yet the multitude of programmes lack a common standard for best practice, despite core competencies comprised of knowledge and skills considered essential, and a lack of universal acceptance (Daily et al., 2010). A literature review of 16 research articles also concluded that implementation and standardization of education in disaster response, disaster plans and surge capacity was not done well in the acute setting, and that more focused research would only be possible once gaps were properly identified (Chapman & Arbon, 2008).

An important question is whether there is sufficient evidence that current core competencies are effective in relation to satisfactory disaster outcomes. A literature review conducted in 2004 examined training methods used in mass-casualty incidents and concluded there was a lack of strongly evidence-based competencies in disaster health response (Hsu et al., 2004). More recently, Daily et al (2010) state that there is little evidence relating disaster health competencies to outcomes, due to the infancy stage of disaster health as a discipline, with none of the competencies they reviewed having been validated, and no evidence one set of competencies is any better than another; a similar result was found by Slepski (2007).  The best method of training, and the frequency of training for optimal preparation of nurses for disasters has not yet been identified, with tabletop exercises, disaster drills, computer simulation, conferences, satellite broadcasts and continuing education the most commonly used (Lynn Slepski & Littleton-Kearney, 2010).

Where to place disaster training in the curriculum

Optimal timing for teaching disaster core competencies is also yet to be determined: whether as an essential part of undergraduate nursing curricula or as postgraduate education. A descriptive study by Jennings-Sanders and Frisch in 2005 examined nursing students perceptions about disaster nursing and found that nursing students had significant gaps of knowledge of disaster nursing (Jennings-Sanders, Frisch, & Wing, 2005). The authors concluded that disaster nursing should be taught as a specialty in undergraduate nursing programs. Veenema (2007) argues that competencies could be integrated into a number of already established units of study in the nursing curriculum in the USA. Kako and Mitani (2010) suggested that the basic core competencies be added to the nursing education curriculum, with the development of advanced competencies in the future with a broader perspective to include disaster areas other than the acute phase. A retrospective review conducted in USA however found that despite nursing schools including disaster nursing in curricula nursing faculty was not prepared nor confident to teach it (Strangeland, 2010).

A similar picture has emerged in Australia. A descriptive survey of Australian undergraduate nursing curricula found that there was negligible disaster nursing content and practice, limited interest in future inclusion of disaster nursing, with little importance given to it as an undergraduate issue, despite nurses being the major professional group to be called upon to respond when a disaster occurs. The authors recommended that a major impetus from registration boards would be required in order for disaster nursing to be included into future undergraduate nursing curricula (Usher & Mayner, 2011). In a paper presented at the 8th International Conference for Emergency Nurses, Canberra, Australia, in 2010, Jamie Ranse discussed research conducted into the disaster content in postgraduate emergency nursing programmes in Australia in 2009. The researchers concluded a national framework was needed for greater consistency as there was great variation in postgraduate courses, with disaster content not included in all postgraduate programmes (Ranse et al., 2010).

International Council of Nurses (ICN)

The ICN (2009) considers inclusion of disaster nursing education in basic nursing programmes to be essential, as well as post-basic, and continuing in-service education. The optimal timing for disaster nursing education is a possible area for future research but the number of annual competencies already expected of the average nurse in Australia may be a significant inhibiting factor if included as continuing in-service education.

The financial cost of disaster education to equip nurses with core competencies must also be considered. In the USA especially, as a direct result of 9/11 and Hurricane Katrina, there has been a greater awareness of the lack of disaster preparedness and vulnerability to future disaster and terrorist events (Daily et al., 2010; Gebbie & Qureshi, 2006; Veenema, 2007). Much of the literature on competencies is published by US organisations, despite the majority of disasters occurring outside the US (Daily et al., 2010). By region Asia had the highest disaster occurrences in 2011 (over 44%) with 82% of people killed, 94% of people affected, and over 88% of the economic damage (Asian Disaster Reduction Centre, 2011). Disasters have catastrophic impact on development on poorer, developing nations with funds needing to be diverted from essential health programmes to deal with the impact (International Council of Nurses, 2009; Kingma, 2010). The cost of disaster education and disaster research is such that it is important that core competencies are effective in relation to good disaster outcomes, particularly in those countries with fewer resources, where a disaster may cancel out years of development (International Council of Nurses, 2009).

The scope of practice of nurses in a disaster is also an important issue when considering core competencies. Gebbie and Qureshi, (2002) considered the importance of personal attitudes such as a nurse’s response to their own limitations when asked to perform tasks outside of their normal scope of practice (for example, adult care nurses being asked to care for paediatric patients) and willingness to communicate this to others in more senior roles. Slepski (2007) found that many HCWs involved in Hurricanes Katrina and/or Rita were asked to work outside of their normal roles or with patients groups they were unfamiliar with, such as paediatric or geriatric patients.

As nurses frequently have to work outside of their normal scope of practice in a disaster some of the difficulties of using competencies as the basis for development have been identified (Daily et al., 2010, p. 392):

 (1) Disasters occur infrequently and can result from numerous and varied events in disparate settings and conditions

(2) Multiple professions and disciplines are involved in healthcare management during a disaster

(3) Many unique roles and tasks are required during a disaster

(4) Different levels of performance of some competencies may be acceptable and/or necessary.

Following the Wenchuan earthquake, Yin et al (2011) concluded that the scope of practice for nurses in a disaster needed to be expanded. Fitzgerald, Aitken, Davis and Daily (2010, p. 110) have stated, Conditions during disaster mandate that practice restrictions be altered. While it is not the time to learn to be a neurosurgeon, it is a time when flexibility about who does what and when is paramount”. In a pilot study of HCWs involved in Hurricanes Katrina and/or Rita a notable finding was not lack of disaster related knowledge or skills but the need to change from normal work practices to ones necessary to practice effectively in a disaster. This “transition process” was recommended as an area for future research (Lynn Slepski, 2007, p. 110).

soon – part two!

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Why the MBBS docs are thinking twice about serving in earthquake zone May 29th


The truth

I know a doctor here in Nepal who once spent a month trekking from village to village in his district, working with every VDC, to examine women and find the ones who could benefit from a specialized surgical camp set up by a German charity group.  And for every doctor and nurse in Nepal, going on a “health camp” to a rural area is part of normal practice.

The innuendo

On May 26th, there was a short article in Republica newspaper bemoaning the fact that 300 doctors are needed in the earthquake-affected areas of Nepal,  and only about 19 responded to the government’s call to work in the earthquake zone. The writer was heaping shame on the young doctors of Nepal.

The response

I wrote a quick response, since the volunteer project I do here in Nepal involves working with those very same doctors, at the beginning of their career.

Today on Twitter I see that the original article has been retweeted more than a hundred times, and seemingly refuses to die. I replied to the retweets offering to give more info as to why young docs might be reluctant but – the writer of the original article did not call me.

Don’t pay  attention to Twitter?

I am aware that Twitter is a bit shadowy. Many of these people who tweet are seeking sensational stories and false outrage. Any twelve-year-old with a mobile can tweet. We don’t know who is “serious” – so, often it’s best to ignore them.

But this time I will be a bit more direct.

Here is what the young doctors are being asked to do, from what it sounds like.

1) go to work in a recent earthquake zone where the houses, schools and health posts have been destroyed.

2) live in the same kind of temporary structure that the people they serve are living in, just as exposed to the elements as the others;

3) Use a temporary structure as a clinic, just like the one that they are living in. There will be no guarantee of a recordkeeping system, no X-ray equipment, no lab equipment, not even a microscope. Not necessarily an examining table, no medical supplies accumulated from the past. There will be no way to dispense drugs if they write a prescription. If there were supplies at that location in the past, they now lie in a heap under rubble that used to be a health post.

4) there is no security personnel. There are reports that the aid now being delivered gets hijacked by village strongmen. Even before the earthquake, there has been a problem with aggressive behavior toward doctors when things don’t go well; the problem with “thrashing” has not gone away and will most likely get worse – the doctor’s physical safety is in doubt.

5) there will be no guarantee of a senior doctor of any kind to supervise or provide advice.

6) In many cases, the young doctor has never lived in a village – they grew up in Kathmandu.

Does this list help? Do you get the picture?

You can’t provide the kind of medical care you were trained to provide, on a picnic. You need tools.

You can’t do it while you are on a two-year’s long camping trip. How does the doctor get food and water and laundry?

The young doctors who signed a commitment to serve and repay loans, could not have known they would be asked to serve in an earthquake zone. Not even Albert Schweitzer would work under these conditions. Many of these young doctors are the same ones who rushed to the affected areas to provide immediate relief in the first weeks. They are not lacking in patriotism. In fact, a few of them did grow up in a village setting. In my teaching I met one  young doc from Makwanpur who was expert at handling oxen when it was time to plant paddy. But for most? Kathmandu.

The doctors need equipment, a roof over their head, and  somebody to prepare rice while they work.

The Nepal Army is in the affected area, doing the backbreaking work to help the residents prepare for monsoon. But while the Army guys were doing physical training everyday and camping while on maneuvers, the young doctors were in the library. All of a sudden, for all intents and purposes, they are asked to join the Army on deployment.

The government needs to  work on these issues and make an effective plan. The article in Republica resorts to shaming and namecalling. This is not the time to browbeat the twentytwo-year-old MBBS graduates, nor is it time to shame the Nepal Medical Council for bringing up the elements of an effective plan.  With a few more questions  the journalist could have gotten to the other issues and provided a service to the reader.

Alas, he did not.

June 3rd update: The United Nations announced yesterday that it would send fifty special “Medical Camp Kits” to affected rural areas. The UN also supplied the information that there are fifty foreign medical teams still operating in the affected zone. Here is their press release.

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May 28 report of CCNEPal part three


Please read parts one and two. In part one, I summarized the numbers of sessions, the locations and the people who took the 2-day (MBBS) or 3-day (for nurses and nursing students) versions of the ACLS course. In part two, I  gave a narrative of MBBS education in Nepal, with some things that stood out after teaching this population.

CCNEPal and the Earthquake

CCNEPal trained 2,130 Nepali nurses and doctors since 2011, and 800 of them from Kathmandu Valley. I got a FaceBook message May 5th:

I was in thamel when the 11:56 happened. A 5 storeyed building. Glad it didnt give up. I survived. Came outside to see 2 houses collapsed. We dug out 2 people, husband and wife with local resources live shovel. The emergency protocols came spontaneously to me. I was able to stabilize them both physically and psychologically. Then in the late afternoon, I went to Bir hospital NAMS to see if i could contribute as a medical student. I performed half a dozen CPRs and assisted in many other emergency management. Could not save them all though. Saddened me of course. Wanted you to know all this because it is all thanks to you and your teaching approach that everything came to me spontaneously. You did save a lot of lives from dharahara quake through me. Thank you.

Even if that was the only guy we trained, it was all worth it.

to respond effectively in a crisis requires the ability to recall complicated protocols and choose the ones to apply. We use in-class exercises to reinforce the memory, and previous groups have told that

to respond effectively in a crisis requires the ability to recall complicated protocols and choose the ones to apply. We use in-class exercises to reinforce the memory, and previous groups have told that “Joe, you are turning us into Jombies!” – but – you need to be able to decide how to execute – and that’s the serious purpose.

The landscape of Cardiac Life Support in Nepal and the future.

CCNEPal is not the only entity that is trying to bring Advanced Cardiac Life Support education to a wider audience. There are other groups filling specific roles to teach nurses and doctors, mostly Medical Officers ( a few years older than the interns).

The hospitals and medical schools in Kathmandu. Bir Hospital has taught a course like ours to the post-graduate doctors seeking their M.D. (Master’s) degree. Man Mohan Cardiac Center and Shahid Gangalal Cardiac Center have recently started teaching this course to  their Medical Officers, as has Patan Academy of Health Sciences and Grande Hospital. It should be noted, however, that in these locations the interns are not included, nor are the nurses. None of the instructor groups from these locations has ever travelled outside the Kathmandu Valley to the fourteen medical schools located in the rest of Nepal, and CCNEPal often hears “You’re the only one who teaches this who comes to Terai!”

Man Mohan Cardiac Center worked with CCNEPal to train the nursing staff in 2014, the same way that SGNHC did in 2013. We did a training for thrity five nurses hosted by TUTH nursing school; then MMCVTC sent nurses to each session we held at LNC. They have a highly motivated and talented crew, and it was an honor to work with them. CCNEPal has trained nurses from each of the cath labs in Kathmandu as well.

Man Mohan Cardiac Center worked with CCNEPal to train the nursing staff in 2014, the same way that SGNHC did in 2013. We did a training for thrity five nurses hosted by TUTH nursing school; then MMCVTC sent nurses to each session we held at LNC. They have a highly motivated and talented crew, and it was an honor to work with them. CCNEPal has trained nurses from each of the cath labs in Kathmandu as well.

The Center for Medical Simulation deserves special praise and mention. Nepal’s only Official International Training Center from the American Heart Association. There is a lot to say about this Center. I was proud to consult with them as to proper policies and procedures, and the courses they offer are on par with the high standards of the American Heart Association.  The BLS or ACLS card you get from The Center is the Official AHA card. Any doc who wants to take USMLE will find that taking ACLS from The Center for Medical Simulation is considerably less expensive than going to Delhi or the USA. Having said that, the fee for the BLS/ACLS is about 20,000 nrs per person. They offer group discounts.

The Center for Medical Simulation owns a complete set of BLS manikins and awards the exact same course completion card that you would get in the USA.

The Center for Medical Simulation owns a complete set of BLS manikins and awards the exact same course completion card that you would get in the USA.

Videshi groups. It is not unusual for one or the other Kathmandu Valley entities to bring in a group of videshi instructors from an American Medical School to teach the “official” ACLS or PALS course, or one of the other courses such as ATLS or PHTLS. For some reason, every outside group always announces that “We were the first that ever did it.” – Um, no. You can think that way if you like, but – last year’s group from USA was also enticed to come here with that same pitch. And the group the year before that…… near as I can tell, groups of foreigners have come here to teach Nepali docs for more than twenty years. In 2014 I listened politely as a pediatric cardiologist from the Mayo Clinic announced to me that she was involved in the first ever ACLS course at a major hospital. Was it the official course? no. Well then, I’d already beaten them to it by thirty sessions with nurses. No big deal. (and for the record, CCNEPal has taught 70 sessions as of May 2015.)

Special note about foreigners coming to Nepal to teach or train:  study this blog and the CCNEPal FaceBook page; and read my two books. You can not simply transport an American course here and think it will work.

Note; if you are a qualified ACLS or BLS or PALS Instructor or Regional Faculty from USA, contact the Center for Medical Simulation. Send them your affiliation paper work as soon as you book the flight to Kathmandu. You no longer need to bring the required equipment, or improvise. You can now teach in Nepal and use state-of-the-art equipment from The Center – much more efficient than hauling stuff back and forth. The Center also has state-of-the-art simulation tools. They have a “3G Sim-Man” suite as well, which they are just starting to use.

Train-the-trainer is a sexy word in these sort of teaching ventures. In my view, it allows the teacher to rationalize doing the logistics for a session that only reaches twenty people at the max. My estimate is that about 30,000 doctors and nurses in Nepal need this. Train-the-trainer is a drop in the bucket; and since the logistics of setting up a course are daunting, none of the train-the-trainer people seem to actually turn around and teach after having just taken it once themselves. There needs to be a culture of ACLS.  I’ll expand on this in a future blog.

Furthermore, focusing on training the “Top Guys”  never seems to result in sharing the knowledge with the Junior Guys (and ladies). The knowledge of ACLS, and the practice of resuscitation, needs to be widely known at the level of the person who is working in a Casualty Room on an offshift, and not limited to the Senior Consultant from the Anesthesia Department.

Training Nurses Part One Any hospital or school that does not also train the nurses, simply does not have an effective ability to do resuscitation. And any person who disagrees with me is proving their ignorance.  I won’t be polite about this point.

Nurses need to learn how to do this. (don't try this at home. these are trained professionals under expert supervision)

Nurses need to learn how to do this. (don’t try this at home. these are trained professionals under expert supervision)

Training Nurses Part Two if your  hospital has an ICU or ER, every nurse in that area needs to have this training. If they do not, and especially if you do not value it, you don’t have a real ICU. The ability to do critical care is defined by training and teamwork, not by an inventory of equipment. Simple.

In May of 2013, CCNEPal started routinely including an anatomy lab in the 3-day session for nurses, to make up for gaps in science preparation ( something I had done in USA for years). For this we obtain en bloc heart-lug assemblies of mutton from local fresh shops. Here's a shot of the coronary arteries.

In May of 2013, CCNEPal started routinely including an anatomy lab in the 3-day session for nurses, to make up for gaps in science preparation ( something I had done in USA for years). For this we obtain en bloc heart-lug assemblies of mutton from local fresh shops. Here’s a shot of the coronary arteries.

Training Nurses Part Three I think CCNEPal should consider awarding a prize, or a Token of Love, or something, to any ICU that achieves 100% training of their nursing staff. Either certify the nurses with the AHA ACLS course or with something equivalent to the course CCNEPal teaches.

The American ACLS Course has it’s place but does not fit the needs of Nepal.

– The AHA has detailed requirements for “mandatory equipment” for each course. It leads to formidable start-up cost that makes it too expensive. With a bit of imagination,  you can do a course with improvised equipment that is not such a large investment.

This is the stuff  CCNEPal uses to teach the course. Another view of all the stuff, laid out so I won't forget something. note the

This is the stuff CCNEPal uses to teach the course. Another view of all the stuff, laid out so I won’t forget something. note the “CPR manikins” deflated in upper left corner :-)

– The protocols need to be adapted to reflect the clinical practices here, and what Nepal can afford.

– And most of all, the “English only for all discussions” requirement of AHA is not helpful. Click here for some examples of ACLS core case scenarios conducted in Nepal Bhasa. Let’s teach the stuff in the language it will be applied. A nurse or doc can be expert at this even if they speak no English. Because of the way the CCNEPal course is structured, every participant is able to get all their questions answered in the language with which they feel the most comfortable. Yes, most nurses and docs speak English. But – don’t underestimate the potency of this tool.

There needs to be a Nepali ACLS certification system. Sure, you can use the latest research-based findings of ILCOR, but the wallet card needs to have little Nepali flags on it, and scratch out the word  “American.” Click here to read about specific ways I adapt the course to fit Nepal.

Train Intern-level MBBS docs. In my view, the most important curriculum change that needs to take place in medical education is to require all interns to take an ACLS course before they complete their internship.  In USA, medical students take ACLS before they graduate. Nepal needs this.

MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal's future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal’s future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

Establish a national network to teach this. There are twenty medical schools in Nepal, and each should be teaching this. Every B Sc program in nursing needs to teach this.

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May 27th eye-witness report #2 by Nepali nurse from USA after earthquake relief expedition


Editor’s Note; Unita Magar, RN is a nurse who now lives in Omaha, Nebraska. She attended nursing graduate school in New York City but Unita is originally from Rukum district in western Nepal. She is active in NANA, the professional association for Nepali nurses in USA. With her colleagues, she flew to Kathmandu after the April 25th earthquake. Here is the story of her trip to the affected area.

On her FaceBook page she posted 150 pictures. I will cull those and add some to this blog. For now, the text is important enough to rush to print. The words are hers.

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For our first trip, our medical team consisted of 11 health care professionals in total: 4 NANA nurses, 3 NAN nurses, 3 medical doctors and 1 health assistant. Altogether, we were 29 of us with river rats (rafting brothers), a mouse (Frank), mountain cats brothers (Climbers) and a local’s team (Bobby dai and his team).

We were able to see 245 patients in about 9 villages in total. On the first day, all of us stayed at the base. On the second day, we divided the team into three groups. First team stayed at the base, second team went to Yangri and the surrounding villages and the third team went to Yarsa, Chunti, Bhotang Gumba, Thorbang, Meu Gau, Kuldi and Mane Gau. The roads to the villages had multiple landslides – some of them had huge rocks and fallen trees blocking the roads. The teams had to walk or crawl up the rubbles to get to the other side. Our team had one doctor, two nurses, one river rafting brother, one kitchen brother and two locals. Initially, when we left the base, we did not have any locals in the team. We were told by Bobby dai that we would find someone as we walked to the village. We found two locals who were very willing to take us around at Bhotang Gumba, our first stop. The hike to Bhotang Gumba was quite steep. From there, we moved from village to village stopping at a public school that had been badly damaged from the first earthquake for our lunch that consisted of chiura (beaten rice) and dalmot, roti (chapati) , boiled potato, small amount of salt wrapped inside a tissue paper to dip potato in and buffalo jerky. It tasted so good. It took me back to my childhood days, when I would go to fetch woods with group of women in the jungle during my summer visits to my grandparents in Rukum and we would rest to eat our lunch of bhuteko makai (popcorn), bhatmas (soybean seeds) and ussineko aloo (boiled potatoes). It made me nostalgic.

We went from door to door on that day, asking, “Yaha kohi birami hunuhuncha?” (Is anybody sick/ill here?). Sometimes, the answer would be “Yes,” and at other times “No.” If there was any sick person in the house, we would stop by, open our rucksack of medical and dressing supplies, examine the patient, treat, educate and then go to the next house. At some places, we would use the side of the road to place our rucksack and treat patients.

At one of the villages, we used our whistle to alert and call upon the villagers. This particular village sat lower on the same mountain to the village we were treating patients at. It was perhaps 10-15 minutes hike, but with rubbles of stones from fallen houses everywhere it may have taken us longer to reach there. When we blew the whistle and screamed at the top of our lungs – “Yaha kohi birami hunhuncha” (Is anybody sick and needs to see a doctor?), some of the villagers turned their heads around and screamed back, “chaina,” (No).

On the way to the villages, two of our team members slipped through the mud and fell on their backs. Thankfully, nobody got hurt. One of them had left behind her two young sons in the States to help with the relief work. Bless her heart for the sacrifice that she made for the people in Nepal. We also had another didi on our team who also left her young sons, one of them as young as three years old to help with relief work. Bless both of their hearts, only they know what it means to leave behind their young children for a cause.

It took us whole day to cover all the villages. At one of the villages, rice and noodles were being distributed by a local group. We purposefully chose to sit in between that particular village (which we had already covered) and the village that we had yet to see, to capture patients from the village we needed to see yet. The technique worked because the villagers stopped by with their ailments and we were able to see quite a few patients. It was already about 5.45 pm – getting dark and we needed to be at the base by 6 pm. We were tired and without any energy as we kept getting pages from the base camp asking us about our whereabouts. By then we were beyond exhaustion to even answer our walkie talkie. However, we knew and were conscientious about not leaving any patients behind without seeing them.

As we walked towards the base, we stopped by a hotel (only hotel in that village) to treat ourselves to wai wai soup (noodle soup). Oh boy, did it taste good! It had never tasted so good. I practically gulped down the whole bowl in two minutes and looked around to see that my team mates had only eaten few spoonfuls. I felt embarrassed. When the tab came, the total payment was very less than we had thought. Nima didi and I thought, the hotel owner probably gave us a big discount. Simple generous gestures like this was present everywhere.

We then made our way to the base camp joking amongst ourselves – feeling accomplished, although way too late than our curfew time of 6 pm. But, we were all so happy and well-satisfied that we had been able to cover all the villages even if it meant working till dark. Only at night in our tents did we realize about the aches in our bodies and feet.

We could not have done it without our 4 brothers – 2 brothers carrying our backpacks and 2 local volunteer brothers, who refused to be acknowledged for their time and effort. They literally held our hands to help us climb a steep hill, jump from a wall or go across to the other side through the narrow roads strewn with rubbles. Without their help we probably would have fallen and scraped ourselves numerous times. They also acted as our health educators during times when three of us got extremely busy treating patients. They taught the villagers to wash their hands before eating and after using toilets, to boil their water before drinking and not to eat meat of the dead animals.

On that day our team was able to see more than 50 patients. A young boy of about 9 years old was also referred to a hospital in KTM for hematoma on his lower back. He seemed to be in a lot of pain. It took us a while to convince his parents to send him to a hospital in KTM. The mother kept mentioning that they could not leave the next day because there was a “Ghewa,” a funeral ritual to attend to. It was a serious case and the boy could not wait to lose anymore time. We also communicated the need via our walkie talkie with the base. Next morning, two brothers had to run to the village to get the boy so that he would not miss the helicopter. He was airlifted the next morning to Kathmandu with other patients with critical conditions. Satish dai and Ang dai personally contributed money for the helicopter.

Next afternoon, we had to leave for KTM. Our initial plan was to stop by the village Dhap and distribute Phenyl liquid, dettol soap and few other supplies before heading to KTM. This is because Dhap was the only village that had a very bad odor – smelled of something rotten and we were concerned about the public health issues there. However, we could not do so because we had to take another way towards KTM as a vehicle had fallen down from the mountainous road we had initially intended to take.

The ride was bumpy as the vehicle jumped up and down on the gravels. The road was muddy, very narrow, winding and often perched on the steep mountains. This meant if the vehicle missed even an inch on the side of the road overlooking the river, we would all be tumbling and tumbling and then tumbling some more until we reached the bottom. What made me cringe and hold fastened to my seat was that the driver would look at the passengers instead of the road while talking and driving. At one time, I even pointed it to the driver dai ; perhaps it was rude but I couldn’t resist.

Just before we reached KTM, our tire got punctured. Perhaps, it happened for a reason. Fixing the tire took us about thirty minutes and this made us reach our destination thirty minutes late, but what we were met with on the way we could not believe our eyes. We were distressed to find a driver stuck inside the truck that had landed on its head on the side of the road as it slipped from the hill above. It was drizzling as well. The truck had slipped from the exact location our vehicle was parked. The skid marks from the tires were still visible – scary! It could have been us. The truck was vertically standing on its head with its tail in the air. Talk about disaster! Just then a van full of police also drove by and we directed them to the accident on the road below. The driver was finally rescued by Ang dai and the team after numerous attempts. The rafting brothers took care of the crowd control while the medical team attended to the driver. The conductor apparently did not get hurt. Initially, I was also made to hold hands with the rest of the crowd, while I struggled to explain to them in the dark that I was also part of the medical team and I needed to deliver supplies to them. The driver was conscious, however his face gave an expression that he was in shock. While we were still busy applying bandages to his visible injuries ambulance arrived and he was taken to the hospital.

By then I had sort of become numb after seeing so much in such little time. If I was feeling this way just by seeing them, what about the people who have experienced so much loss and in so little time? I cannot even imagine. But, such strong, resilient, generous, humble and content people filled with so much gratitude even with all their losses – offering you their tea, their limited food and resources even after knowing they may not have enough. What we were doing was very little compared to their gratitudes and generosity. May God bless them for eons and eons and give them strength to live through this. Bhotang VDC, you will always have a special place in my heart.

Thank you to our local volunteer brothers for bringing villagers in some villages. The villagers were ready for us to see them when we reached there.

Conditions we encountered most were URI – dry cough, stomach ache, GERD, headache r/t PTSD?, ankle pain, muscular pain, wounds, cuts & injuries r/t earthquake, I & D, diarrhea, a case of ascites, a case of CHF, and few other conditions.

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I will add some photos from her FB page. If anybody wishes to get in touch with Ms. Magar, send me a message and I will get it to her.

Also – in Kathmandu. I am told that the inpatient areas of most hospitals are having very low census right now because nobody is having elective surgery. Also, no patient seems willing to be admitted to a room on the second floor of any building, so the hospitals are reconfiguring to keep as many patient beds on ground floor as possible. Finally, the families are insisting to be with their loved on at all times. I know some will think this is a generalization. But – it’s what I have heard…..

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CCNEPal report may 26th, 2015 – part 2 – how MBBS medical education works


Update May 27th, 2015 – in Today’s news, an article about the Ministry of health and the difficulty faced in assigning young MBBS doctors to the quake zone. click here. I invite the government to learn more about my small project and what I have learned, that will help this problem. We have been working on a solution to this exact issue, since 2011.

Part two. There will be two more parts after this. 

note: I am an outsider to the system, and I know that there will be people to say this is not accurate etc. Any reader who wishes to complain is welcome to submit a comment. If you can help me make this better, I appreciate. I would love to “cloud source” this to make it the best possible. If you are not comfortable with commenting due to sharing your name, send an email to joeniemczura@gmail.com and I can incorporate your feedback anonymously.

This is the second part of wrapping up activities for CCNEPal in 2014-2015.

I am writing for an international audience, and I feel the need to take a detour in the report of activities. The medical education system in Nepal is not a one-to-one equivalent to USA. When I work with MBBS docs here, there are different needs than USA med students would have.

About the Medical Education system of Nepal

Here is the career path.

1) Go to school and pass SLC at the age of sixteen, then take two more years of science courses.

2) Enroll in Medical School as an undergraduate in Nepal. The degree is named “Medical Bachelor’s, Bachelors of Surgery ” – MBBS

MBBS is four years of school and one year of internship. during the school period, there are electives for various rotations.  There is no specific critical care rotation, it is included in the rotation for anesthesia. Note: most other rotations are two months but anesthesia is usually about two weeks – about long  enough to develop some practice managing an airway and performing endotracheal intubation. MBBS docs do not learn ecg in the format of an organized course- they are told to study that on their own. They typical MBBS graduate can not read an ecg rhythm strip.

3) On graduation from internship, the person is called a “Medical Officer.” If they do not have government loans, they are free to go anywhere. If they do have loans, they owe two years of service in a rural area to pay them back.

At some point after the two years, they can take a “Lok Sewa” exam ( civil service) and become a permanent government employee.

4) After a period of time, they can return to school for a “Master’s” – the post-graduate course- and become a Medical Doctor. Also known as a post-graduate doctor.

That’s the bare bones.

Government Policy Background

The government of Nepal has expanded the number of medical schools in the country over the past ten years or so, and now there are twenty.  Click here for a nifty infographic. Prior to the earthquake there was a big scandal in the country because the government was planning to award permission to open four more schools, and there were nationwide protests led by Dr Govinda GK. At that time, the news coverage focused on government corruption in the health sector. (that’s why the Kathmandu Post generated the infographic above.) The pool of senior doctors in Nepal to run all these schools is stretched thin due to rapid expansion.

Because of the lead-in time, only recently have larger numbers of MBBS grads come out of the pipeline. In some cases, the schools are specifically saying they wish to produce people who are prepared to serve in the rural areas.  The schools market the idea that they will help address the shortage of medical care in rural areas by setting up better-supervised placements in support of the recent MBBS grads doing this role. Read here for a description by a supporter of PAHS, one of the medical schools that markets this idea.

Key Points

There are key points I have learned from interview with students about their perception of the education at this point in their development.

The undergraduate degree is science-based, focused on book learning and reading, and does not presently use simulation learning or case-based learning.

The MBBS undergrads are allowed to tag along on clinical rounds but are “junior” to everyone and in many cases, are not allowed to speak.

Senior vs. Junior is an issue

MBBS interns in many cases, have never written “doctor’s order” or collaborated with a nurse. They are not allowed to participate in emergency response. They generally have not taken a BLS course. They can not reliably interpret an ECG.They have never given a “verbal order.”

The MBBS grad has read about psychiatric counseling, but the curriculum does not include opportunities to personally apply the skills. Mental health is a very new field in Nepal, land of Saddhus.

Specific education for rural practice is not included.

In this article, the author makes a point to describe the educational needs of students before they go to the rural area.

There is no support from post-graduate doctors to the Medical Officers in the rural postings in most cases. There is no structured program of professional development.

The threat of physical violence from family members of patients is real.  This last statement may be a shock to people who wish to believe that Nepalis are a kind, hospitable, loving family-oriented people.  To say otherwise would hurt Nepal’s marketing as a tourist destination. And so – nobody talks about it. It is hidden from the tourists. The threats of violence, and the actual violence, is not something the average 22 year old geeky med student kid from Nepal is prepared to deal with.

There is presently a pent -up demand among MBBS Medical Officers to take USMLE and continue their studies in USA. The young docs have heard that the USA system is different and they want to see for themselves. Maybe they will return to Nepal;  they all have an attachment to the culture here. But, Nepal is not immune from the “Brain Drain.” Click here for an article that describes a study about Nepali MBBS practicing abroad. The link is to a newspaper article describing a study published in the British Medical Journal. In that study, it gives the statistic that one-third of graduates in the sample from one medical school, are practicing abroad.

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