Announcing “The Himalayan Zap Trek 2017” GoFundMe campaign


Mention Nepal and everyone thinks of #Everest.

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at the end of the time in Biratnagar, the farmers planted the entire paddy behind the guest house, as well as others. during this period, it’s like the hospital is an island in a large lake that’s only six inches deep. I left one day before the torrential rains began for monsoon 2016.

Thirty million people live in Nepal, and 99.999999999% of them do not live anywhere near Everest.  Nepal also has a large rice-growing region, where western tourists are rarely seen. See the above photo!

Since 2011, CCNEPal works on a project to improve health care for those people.

Maybe that’s a little vague. Try this:

Imagine a hospital with no Code Blue team. Nobody knows CPR, they don’t do “Rapid Response Teams” and if a patient crashes due to a predictable complication after routine surgery, it’s a hit or miss proposition as to the outcome. That’s the situation for most hospitals in Nepal.

It’s easy to say “Oh, it can’t be helped. Nepal is a low income country after and they are used to a short life span.”

CCNEPal’s answer? Yes it can be helped! Our answer is simple: we teach critical care skills in a two- or three-day intensive course based on the ACLS course of the American Heart Association (we adapted the content to fit Nepal and it is not the “official” course). We have taught ninety sessions, and given certificates to 2,885 nurses and doctors in that time in many regions of Nepal. We have created widespread awareness of the training and recognition of the need for this training after five years of work.

In 2017 the plan is to build on this work. In the past CCNEPal was privately funded but we need to find a new source of funding. So – The Himalayan Zap Trek 2017 was born.

What is a “Zap Trek”?

“Zap” is the sound made by a defibrillator when you shock a dying patient. (actually, “zork” is a more accurate term, but “zap” is used by doctors and nurses worldwide, so zap it will be). “Zap” is an onomatopea.

A “trek” is a long-distance hike in Nepal, such as the “Annapurna Trek” – considered to be the finest such experience on the planet and a lifetime bucket list item for any diehard outdoorsperson. http://www.backpacker.com/trips/international/the-perfect-circle-hiking-the-annapurna-circuit/

CCNEPal teaches how to defibrillate; we travel; therefore the name was born.

CCNEPal eschews trendiness, but – Zap Trek 2017 will have a trendy appeal.

GoFundMe site.

If we can get funding, our goal is

-to stay in Nepal for five months;

-teach 2,000 people;

-provide materials and equipment for hands-on training.

-teach at ten or more Medical Colleges, including every Medical College outside Kathmandu Valley; and

-improve our network of on-site trainers in all the large cities of Nepal, so that the training becomes embedded everywhere. If you browse this site, you will see our track record of success, but more needs to be done. For this reason, we have set up a GoFundMe site.

https://www.gofundme.com/zaptrek2017

We’ll post a detailed budget breakdown in coming days.

Please share this widely.

 

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The Three-legged Stool of Global Health Nursing – for October 15th in Boston!


Nurses: A Force for Change: Improving Health Systems’ Resilience

above is the title of the Oct 14th and 15th 2016 meeting of Boston’s Global Health Nursing Caucus (in Boston of course!) and the event can be found at:http://seedglobalhealth.org/nursing-conference/#.V96VLIf2Zjo It’s co-sponsored with SEED Global Health.

Lightning Talks between 11 and 12:30  the 15th

They’ve made space for “lightning talks” – five to ten minute presentations modeled after the popular “Ted Talks” – a chance for the speaker to present just one idea. This is a great idea – the best meetings are ones where you can learn from the other attendees as much as from the presenters. This gives people the chance to figure out who is in the audience next to them.

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these ladies are wearing “paranda” – a traditional tassel or hair extension. I got a lot of these for the C.U.G.H. meeting last spring.I have some remaining and I’ll bring them. Want one? just ask!

The Three-Legged Stool of Global Health Nursing

That’s the title of my lightning talk. I needed to focus on just one idea, and that’s what I chose. It’s the most elegant way to think of how to advance nursing in Low Income Countries. Some projects succeed, some fail. Sometimes you see things that you want to change, and which can’t be changed no matter what you try to teach or do or model or support.

The three legs compose a “Schema” of interrelated phenomena. If you try to change one, without addressing the other two, your stool will not be level, and may collapse when you try to sit on it…….

First leg is culture and the role of women.

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medical colleges in Nepal are working on “gender balance” but nursing is still female. The solidarity to be found in an all-female work group in Nepal is inspiring. There is an upside to go with the downside….

Second Leg is the nursing education curriculum and system.

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seen on a classroom whiteboard of a PCL nursing school in Kathmandu, Nepal. Students there are regimented; they learn to love it, and even if they don’t it molds them a certain way…..

Third leg is the setup of nursing service. To understand nursing in a low income country, you must understand Functional Nursing – click here – http://www.austincc.edu/adnlev1/rnsg1413online/mod_prof/nsgdelivery.html

Study the above! ( don’t confuse it with the argument about “functional vs. dysfunctional,” that’s a whole ‘nother animal entirely).

got it?

 

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some three-legged stools are fancier than others. Here is one with “patina” – age marks that make it beautiful.

How does it work? well, my best examples are from Nepal, of course since that is where I work.

The nursing service system is organized to provide “Functional Nursing” which is to say, task-based nursing. The hospitals are not staffed to provide individualistic nursing care such as we would think of with “primary nursing” or “team-based nursing.” Oh, individualized nursing care can happen, but it is on a  hit-or-miss basis.

The educational system (especially of the PCL level) teaches functional nursing. As long as the hospitals want and need functional nursing,  the PCL nurses will provide it.

Functional Nursing depends on the idea that nurses do what they are told and don’t generally ask questions. Functional Nursing is a way to get the mandatory tasks done with the least number of people – in that respect functional nursing is not good or bad, it is just  “is.”

which brings us to –

The role of women in the culture.  In Nepal, the traditional role in involves deferring to the judgment of males, or deferring to the doctor, or deferring to who ever is “senior.” In that respect, functional nursing is elegantly matched to the culture.

If you as a foreign colleague see an opportunity to “improve things,” you need to resist the urge to jump in and implement something in one of the three legs until you have assessed the impact on the other two legs. This schema can be used to assess whether a given intervention is “sustainable.”

That’s enough for ten minutes, don’t you think? If I were to exhaust the topic, I could roll it on into about eight hours of presentation.

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CCNEPal begins planning for 2017 in Nepal – taking it up a notch?


CCNEPal began a special project to upgrade critical care skills of nurses in 2011. Since that time we have trained 2,885 nurses and doctors to perform cardiac life support skills using scenario-based teaching, which in itself is new to Nepal.

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All the props, packed up and ready to travel. CCNEPal 2016 was essentially one loooong road trip. What will we do in 2017?

2016 was lots of fun.

We conducted 24 sessions of the two-day or three-day course and gave out 715 certificates. We helped with initial training of ICU staff in some locations that were starting their very first ICU. We mostly focused on Terai (and a two-week stay in Pokhara). We taught MBBS docs from five different medical colleges.  We added three sessions in Kathmandu at the end of the summer and these were terrific.

What to do in 2017?

possible dates would be June, July and August 2017. It’s all flexible until the day I buy the ticket.

supplies for class

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 magic formula?

Seems to be to conduct more of these sessions. If you would like to host CCNEPal in 2017, send an email to joeniemczura@gmail.com.  Wnd all the will respond by adding you to the queue, and telling you what we need in order to have a successful class ( browse the rest of this blog or else look at the FaceBook page to learn what the set up of the classroom involves. We need lots of space and a minimum of thirty participants to attend all three days).

We do not charge for this; if you are in Kathmandu Valley we request that you provide transportation. If you are outside of Kathmandu Valley, we ask that you provide fooding and lodging. We do not require a tourist hotel, just simple accommodations for one person.

There is no magic formula!

Not one that must always be applied. CCNEPal is open to suggestions as to activities for 2017. We need to always consider how to take this program and incorporate it into the professional curriculum, instead of being the add-on for those who have already graduated.

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An ICU at a Teaching Hospital in Terai. Foreigners often have this fantasy that they will be in some mythic village somewhere, delivering health care to some sort of colorful ethnic group. In fact, there are modern hospitals, a system of medical and nursing education, and most of all, a collaborative approach to sharing knowledge.

I’ve been wondering about having some sort of sessions specifically for faculty of schools of nursing that want to learn how to teach this. In the B Sc curriculum, I’m told that there is a 16-hour time slot for “ACLS” – but many persons were not aware what this meant. ACLS means using this type of scenario-based teaching!

Why not have a conference to share these skills and teaching approaches with everyone? In my fantasy it would be a national conference with nursing faculty from all over Nepal!

It’s just an idea at this point, but I am putting it on a string and seeing if it will fly like a kite….. putting it in the bathtub to see if it will float ….. running it up the flagpole to see if anybody will salute….. let me know what you think…..

 

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Biratnagar Part three – a few scenes of Nobel Medical College August 2016


This is the third of a series about the two-and-a-half weeks I spent teaching critical care skills at Nobel Medical College in Biratnagar Nepal. I taught 200 nurses and MBBS students and doctors, there.

When I posted the blog about the Nepal Burn Center, my friends from Nobel sent me a reminder that they also participate in the Nepal Burn Network and collaborate with ReSurge International. In fairness, Nobel has a wide range of services including cardiac catheterization lab, and they participate in many international initiatives. But I’ll keep this short and pictorial.

This one will describe a bit more about the ICU at Nobel.

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Nobel Medical College in Biratnagar has a majestic driveway, and it is a nice touch that the designers left the chautara at the beginning intact.

Resource Nurses

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the two nurses in dark green are “resource nurses” – in a role similar to “in charge.” The ICU at Nobel is about 30 beds, but the physical layout is somewhat unique compared to most ICUs in Nepal. ICU is a series of rooms, with about five beds in each. each of these pods is semi-self-contained, but the nurses in the resource role float from room to room. Srijana (on the right) had taken my course at Hotel Namaskar ew years back and I was delighted to see her again. she was one of my “assistants.”

The census

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one of the census boards. This is publicly viewable, which would be a no-no in USA, but still okay in Nepal.

planning

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for the in-charge nurses, the day begins with report on the status of every patient

Medicine Preparation

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bedside medication. they tried to stop me from taking this pic “it’s never this messy!” but I wanted to show how it’s set up. Meds are purchased by the family as ordered, using the pharmacy downstairs, and brought up to the patient’s bedside. There is also a stock medicine cart for emergency meds.

Room set up of ICU

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the stock emergency med cart is against te back wall, left of center. nobody uses abbojects in Nepal, it’s all in ampules and vials. The patient on the right is being ventilated. The head of each bed is detachable. In this particular hospital, there was no distinguishing features of the room to remind you which of the six rooms you were in.

In the above, if you look closely you can see that one nurse is hanging an IV on the same pole that holds a syringe pump. Here, they have piped-in oxygen and compressed air and well as wall suction.

the inpatient pharmacy

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when the doctor orders a medicine, the relative takes the scrip to the inpatient pharmacy where it is filled. always busy. these pharmacists did one quirky thing: hen they opened a carton or extra packaging, the trash went to the floor and stayed there – at times they were walking on accumulated trash six inches deep. they collected it during the slow times for disposal.

family waiting

Every patient is expected to have family available. I did not tour the ICU at night ( I realize I should have) but during the day the family waited outside ICU at the adjacent inner courtyard. it always reminds me of a bus station.

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One of the families, waiting outside ICU. the sleeping pad is rolled up.

Emergency Room

panoramic shot:

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Panoramic view of ER at Nobel.

I took a tour of the Emergency Room at Nobel, and made a short video. It’s a large open bay with about thirty beds, so I was interested to learn how they organized it. When a western person sees any such place, the first reaction is usually “OMG!”  but there is a system that goes with it. They use the “Australian Model” –

Time passes

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at the end of the time in Biratnagar, the farmers planted the entire paddy behind the guest house, as well as others. during this period, it’s like the hospital is an island in a large lake that’s only six inches deep. I left one day before the torrential rains began for monsoon 2016.

 

 

 

 

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Biratnagar 2016 excursion part 2 – the sessions


In summer 2016 I spent two weeks teaching in Biratnagar, Nepal. Though it’s the second-largest city in the Himalayan country, it’s not on tourist path. In the first part of this series I described a few things about the town. Here is what the teaching was like…..

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the suite of rooms included many tables with green drapes. Nobel has just purchased a set of simulation manikins and they are developing the simulation capability. For my own sessions, I only used the equipment I brought (plus borrowing a defib and a monitor and I was careful not to let the students play with the new tools). What was under the drapes, stayed under the drapes.

Nobel got their manikins from “General Doctor” a company based in Shanghai. here is their website: http://en.honglian8.com/products/Products-del9737.html

The Classroom Space

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panoramic view of classroom space. I asked them to bring the beds, for the small group work. the space was ideal for our training and I recommended to them to keep the beds there. in this pic, the groups are working on scenario practice, a key component of all such courses.

Lecture time

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Nobel Medical College Teaching Hospital has a suite of classrooms including a very large and modern space for skills training. One end was supplied with chairs and a white board. we could jump from one configuration to another seamlessly.

;;;

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from the outside, the suite of classrooms is nondescript, as a matter of fact, to get to it you needed to walk through an area under construction so it had a sort of abandoned feel. But it’s on the hospital end of the large building complex. Once you got inside it was nice. It is a fine setup for teaching

Simulation equipment, anatomically correct

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okay, so when you invest money in a complete set of simulation manikins, you get the ones used to prepare nurses and doctors for Labor and Delivery. Post-partum hemorrhage is a leading cause of maternal mortality in Nepal, and a a good outcome requires a successful team response. In Nepal, a training certification effort known as “Skilled Birth Attendants” uses these. In this regard, using scenarios to drill on delivery will lead directly to better outcomes. Nobel Medical College is to be commended for their commitment to training that will benefit the region.

Simulation equipment

Effective use of the defibrillator is enhanced when you train on the device you will use in clinical practice.

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on the first day of class, the MBBS students arrived in their clinical uniform which includes a necktie and a white lab coat. Here, they are reviewing use of a defibrillator. please note that the paddles are disconnected from the power source, for safety.

My contact person from the anesthesia department

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my contact person was Dr. Bandana Paudel of the anesthesia department. She had trained at Nepal Medical College in Jorpati, and we both knew Dr. Gautam Bajracharya, one of my favorite docs in Nepal. For me, I love it when I meet a new person whose sense of humor matches mine. Dr Paudel is a champion of hands-on training in Nepal.

One of the defibrillators

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Nihon-Kohden. Nobel has a cath lab and this is their “go-to” machine. in combination with my Pinnacle Technologies AT-35 rhythm generator, we gave students confidence in this machine.

second MBBS batch

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after Day One, the Nobel College MBBS group got hip and arrived wearing the polo shirt (non-clinical) uniform, more comfortable in the heat. Al the Nobel groups shared one characteristic: they were incredibly focused. By that I mean, you could hear a pin drop when I was lecturing; they took good notes; they jumped to do the things I asked, and there was no horsing around. Some days were really hot, and they worked hard with no complaints even though everybody was sweaty. And I almost forgot: one of the MBBS batches included a subgroup of Maldivians. I gave them permission to act out the scenarios in the Maldivian language. Which they did. It was fun.

;;;

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Dr Paudel maintained an anesthesia clinical schedule while the sessions took place, but I laughed when she came to help. She was the only colorful person in a sea of black-and-white. Please don’t misconstrue this comment – Dr Paudel uses the fuchsia outfit to command attention – in USA we would call this “power clothes.”

helping out my friends at Center for Medical Simulation

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I gave out brochures for the classes offered by my friends at the Center for Medical Simulation in Kathmandu, Nepal’s only “Official” International Training Center for ACLS with the American Heart Association.

http://www.medsimulationnepal.com/

Lunch al fresco

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on teaching days I preferred not to go all the way to Guest House to eat, so I shared meals at the canteen. This was quite pleasant. I always tell people “No, I’m not teaching under a grass-roofed hut somewhere!” but, I did eat a few meals under a thatched roof.

five assistants

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for each session, I recruit leaders from among the group. Here are five who served as “my assistants” for one of the nursing sessions. And Shahruk?  ask me about him sometime when we meet again.

Nursing staff

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Jamuna Bhatterai is Matron of Nobel Medical College Teaching Hospital and also campus chief of nursing college. she has a M Sc degree from BPKIHS and she participated in the role play. The puggri? it is not worn in this region of South Asia as a rule, but – it’s fun. And since she is “in-charge,” she also wears it as “power clothes.”

one of the group shots. I taught twentyfour sessions overall,  of which six were here. Two hundred trainees at Nobel – wow. On the FaceBook page, one album shows all groups. I always stay until everyone gets a photo with me if they like.

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One of the nursing sessions. The first batch of nurses were really fired up about what they learned. This created a dilemna because the ones unable to go complained. So the administrators asked if we could add a session. Which we did. They approached the training with a wonderful attitude.

acting worthy of Bollywood

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As always, we did the “family counseling scenario” on day three. I’ve written extensively on this in previous blogs. The nursing groups at Nobel Medical College included excellent acting, but – the amazing thing was that they met the challenge by applying some very specific things from their own customary practice. Probably the top two of the best executed responses in the whole time I have used this scenario. I was blown away.

Training with the work team

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part of the cath lab crew. Biratnagar does caths and pacing; you would have to go all the Bharatpur to find the next place in Terai (BPKIHS in Dharan also does these procedures). Over the three days they did  about forty scenarios together. When they next have a critical situation in clinical, they will be a team.

Role Play scenarios

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we don’t normally give the security guards much thought, until we need them. The “Gorkhali topi” is widely worn by chowkidars. Recently I read that this is considered a stereotype by members of the Gurung ethnic group. Okay. I’ll come up with better props for next year.

Felicitations

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at the end of more than two weeks, we had a “felicitation” ceremony in which we acknowledged the work done by all the nurses and doctors. They gave me some nice “tokens of love.” Here I am with Mr. A.G. Singh, the Principal of Nobel Medical College. ( and Jamuna Bhatterai, the hospital Matron)

At the end of the time in Biratnagar,  we had a gathering in which we memorialized the effort. This is a expression of collegiality in Nepal, and I get boxes of these “tokens of love” by the end of the summer. Call me if you need some Nepali bric-a-bracs.  I hope to return to eastern Terai in future travels.

Part three of this series will show the critical care units and a bit more about the hospital itself.

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Biratnagar Nepal – a jewel of the Terai July 2016 – the town


In late July, 2016 I spent more than two weeks in Biratnagar, Nepal, teaching critical care skills to nurses and medical students at Nobel Medical College. This is Nepal’s second-largest city, in the eastern Terai, generally acknowledged as the center of industrial activity for the country.

Nobel Medical College was my host. http://www.nobelmedicalcollege.com.np/

As with my recent series about Janakpur, this  will be more than one part. First, I’ll describe the highlights of the town, then go to the classes and finally some photos of the ICUs there.

Hotel Namaskar

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This is a favorite business hotel in Biratnagar. the two restaurants on the premises were very good. out back was a party palace.

http://www.hotelnamaskar.com.np/ I stayed at Hotel Namaskar my first trip here a few years back, and on that occasion I was sponsored by “CNE Planet,” the brainchild of Raj Mehta and Dipty Subba.

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Dipty is very organized and has shown initiative in continuing education for nurses in Terai. The “puggri” is not native to Nepal, but I use it as a prop for the class. It helps to get people out of their comfort zone and into the Land of Make Believe when we do complicated simulation scenarios. Naturally the headpiece includes real diamonds, rubies, emeralds and sapphires….

Hotel Namaskar is near “traffic chowk” and I never did return to it on the long 2016 trip. Traffic chowk is more pedestrian-friendly than the spot I was in, as I recall.

Videos

I didn’t shoot these, but they represent the town pretty well, in my humble opinion. You can enjoy these even without Nepali language. It’s a large sprawling city on a plain flatter than a pancake. On a good day, you can see the Himalaya.

Hamro Biratnagar   (“Our Biratnagar”)

Nepali-language video

going down the street video

Biratnagar in New York Times

This city  does not often receive international attention.

http://mobile.nytimes.com/2015/09/17/health/nepal-water-earthquakes.html

This one has a backstory.  Biratnagar fell prey to an epidemic of Hepatitis E in 2014, a year before the earthquake, but nobody was interested from international media. Eleven hundred people contracted the illness in Biratnagar – hey! what does it take for a city to get some attention?!?!?

The New York Times seems to have re-edited this video  after the 2015 quake, adding the first section based in Kathmandu, because of the threat of an epidemic; creating more interest in the Biratnagar section, where an actual epidemic happened.  The miracles of modern technology allow a person of skillful means to slip the bonds of chronological time.

The Biratnagar section the NYT video includes brief glimpses of hospital scenes; yep, that’s what it looks like in a Nepal hospital!

here is the link straight to the video, which is 6:38 long. http://www.nytimes.com/video/health/100000003883905/nepals-waterborne-worries.html

evening street market

Below is a more typical scene. Throughout Nepal this is how people get vegetables.

Geography

The east-west highway goes through Itahari. To the north is Dharan and to the south is Biratnagar. If you are in Biratnagar  in summer and you need to beat the heat, go to Dharan. Here is a 24 minute travel video in Nepali that shows trip to Dharan from Biratnagar.

And now some photos I took myself.

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If you arrive by bus, get off when you see this temple – the road to Nobel branches off here.

Kanchenbara is the name of the Chowk where a side road branches off to Nobel Medical College. You’ll know you’re there when you see the yellow shikhari-style temple.

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Yes, look for the yellow temple, but if you are colorblind, you’ll know you are at Kanchenbara when you see this🙂

 

 

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the shop with the NCell sign is the cyber café and also does photocopying. in Kanchenbara.

If you need photocopy, get it at the cyber cafe located here.

I knew that it would be difficult to find “organic coffee” (i.e., not nescafe…) in Terai, so I brought my own supply but by this time I’d been away from Kathmandu for eight weeks. I always look for “organic coffee” and peanut butter, and – I found it for sale in Biratnagar.

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simple pleasures. Nepali-grown coffee is quite good. I had been running dangerously low on the supply I brought eight weeks previous. Now – I knew I could endure anything that may come my way!

The place to obtain these is the department store at Mahendra Chowk, about 8 km south of Kanchenbara.

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At Mahendra Chowk. This place has “organic coffee!” and yes, that’s a Baskin-Robbins on the right. life is grand!

Near the Chowk is the central Bajaar. On a hot day the open-air plaza is shaded by blue tarps, providing a sort of psychedic effect.

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Was it hot? funny you should ask we’re talking eastern Terai in late July – yes, dear. This is the Bajaar near Mahendra Chowk.

In the vicinity of the Bajaar you can find both the Hanuman mandir and a mosque, with several adjacent shops selling Islamic supplies.

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An unusual Hanuman mandir for Nepal. Usually Hanuman is outside.

 

Biratnagar does not have a religious focal point to rival Janaki Mandir in Janakpur, but people here are similarly devout.

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The mosque at the Bajaar near Mahendra Chowk, Biratnagar Nepal.

Biratnagar has a sizeable Muslim community, with loudspeakers announcing the call to prayer at dawn.

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the fun in exploring a bajaar is sometimes to guess what on earth a particular item is used for. These are clay pipes for “chillum”

Pedicabs

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In Terai the pedicab business took a hit during nakibanda, the petrol “blockade.” Electric-powered jitneys, funded by business interests from India, moved in. But the pedicabs retain their charm, including colorful paintings on the stern. this depicts a Nepali kingfisher.

I stayed at the Guest House operated by the Medical College. This was quite new. Spotlessly clean and a western toilet. Here’s what my room looked like:

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ithe room faced west. I loved drinking my coffee on the balcony in the morning. it was sparkly clean and the guest house staff was attentive. there was wifi.

I used the air con.

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dinner at 8:30 PM around this table. the common areas at the Guest House were ample.

Dinner was at 8:30 PM, served buffet style then  seating around a large table. Like other medical colleges of Terai, most of the guests were supplemental faculty from India. Dinner in Terai is always fashionably late; I have to admit I never really got used to that convention seeing as how I’m usually in bed by nine. The menu was typically “dal baat” with other thakali items. Sometimes chicken or fish also.

Kabadi

Never heard of Kabadi, https://en.wikipedia.org/wiki/Kabaddi the competitive sport, until I joined other guests waiting for dinner. They watched this for hours. who knew?

After watching the above, ask yourself what Kabadi teaches us about the national psyche of a country where this seems to be a major sport.  Here is a link to the rules of Kabadi: http://www.wikihow.com/Play-Kabaddi

Breakfast wasn’t til 8 AM, too late for my tastes; we arranged a simple breakfast every day at 7 and I also got my own coffee at 0530, which was nice. People told me that some previous group of westerners had asked to relocate to some other hotel somewhere; it’s a mystery to me as to what the problem was. The staff was eager to please.

The big entertainment was to watch daily progress on the rice paddies surrounding the Guest House.

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from my balcony at the Nobel Medical College Guest House. The water was six inches deep. They do *not* depend on rain to fill each paddy, it surprised me to learn about the engineering of the water – more to it than meets the eye. Also, I saw egrets. Turns out they were “Indian Pond Herons” – a new species for me.

Nursery beds

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a nursery bed awaiting transplant to the large paddy. The color of newly-grown rice is dazzling. the rice-growing process provides many stories and legends and there is an annual festival when it begins.

There will be two more entries about my time in Biratnagar – one for the classes and hospital, and another for the critical care areas. stay tuned!

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Nepal’s Role in the “Global Resuscitation Alliance” -is there one?


This past week brought the announcement of two new organizations to promote better resuscitation from cardiac arrest, worldwide. “The Global Resuscitation Alliance” and the “Resuscitation Academy.”

wow.  I love an audacious goal, but – I’m a bit of a skeptic.

The two organizations were announced at #EMS2016, an international gathering of EMS personnel.

The history:

A Call to Action

On June 6-7, 2015 at the Utstein Abbey near Stavanger, Norway, 36 Emergency Medical Services (EMS) leaders, researchers, and experts from throughout the world convened to address the challenge of how to increase community cardiac arrest survival and how to achieve implementation of best practices and worthwhile programs. We call for the establishment of a Global Resuscitation Alliance in order to expand internationally the reach and utility of the Resuscitation Academy concept developed in King County, Seattle since 2008. Such a global effort will promote best practices and offer help with implementation to countless communities. A Call to Establish a Global Resuscitation Alliance1

In my Nepal sessions I always discuss the syndrome of Sudden Cardiac Death, just before I introduce MONA. I draw upon the research from Seattle, while we discuss warning signs. Turns out the people from Seattle are  a driving force for this new initiative.

The Call?

from the Executive Summary of the “Call to Action” document

In 2015, twenty five years after the first Utstein meeting, 36 resuscitation leaders gathered at Utstein to solve another problem – how best to implement successful strategies in managing cardiac arrest and how to spread the lessons of best practices. This 25th Anniversary meeting is timely for several reasons:

There is an understanding of how best practices can achieve dramatic increases in cardiac arrest survival.

There is better science on the importance of high-performance cardiopulmonary resuscitation (HP-CPR) and Telephone-CPR (T-CPR; also known as Dispatcher-Assisted CPR (DA-CPR) and Telecommunicator CPR).

There is the emergence of large cardiac arrest registries that provides the platform for measurement and highlights the variability in community survival rates.

There is better understanding of EMS systems and the characteristics of high performing systems.

There are now successful strategies to achieve programmatic implementation such as the Resuscitation Academy, which bridges the gap between science and community best practice.

There is renewed emphasis in the proposed United Nations’ (UN) Sustainable Development Goals for 2030 to reduce deaths from non-communicable diseases including the growing problem of prehospital cardiac arrests in low and medium resourced countries.

Improving Survival from Out-of-Hospital Cardiac Arrest

Nations with emerging economies will experience dramatic increases in ischemic heart disease and an anticipated need for pragmatic implementation of costeffective resuscitation practices.

There is a pdf download that explores the idea of best practices, and the link is:

http://www.resuscitationacademy.org/index.php/2013/03/ra-ebook-now-available-on-itunes/

My feedback

At first I read this with enthusiasm because after all, this goes directly to the issue CCNEPal works on in Nepal. On further study, it’s not so clear. There are issues which are not addressed.

  1. The participants were all from developed countries in the “western world” with small representation from Asia ( there were people from Singapore, hardly a low- or even middle-income country).
  2. The participants all came from countries where there is an highly developed EMS system.
  3. The concepts they describe apply to out-of-hospital cardiac arrest, but in the low-income countries of the world, the educational system and the service system are struggling to reach a goal of acceptable survival even with in-hospital cardiac arrests.
  4. Finally, the sponsoring organizations have a vested interest in promoting only those initiatives that already fit in the proprietary box. For example, in order for a training course to receive approval by the American Heart Association, it must meet   the same criteria when taught in Timbuktu (or Kathmandu!) that it would if taught in the USA. If the goal is widespread dissemination of resuscitation skills, this is simply not practical and it smacks of “cultural imperialism.”

From my own experience?

Here is my feedback to this initiative.  The scope of need is vastly greater than can be met by using the approach now in favor with the developed countries. Considerable “ramping up” is needed.

For the “official” AHA ACLS course, equipment costing about $25,000 is needed. Few in Nepal can afford this investment.

Only the approved DVD may be used for the didactic component, and all discussions, including the debriefing must be done in English (or Spanish is also allowed).

This is simply ridiculous, and has been generally rejected. Obviously a doctor or nurse can be an excellent ACLS team member or leader even if they speak no English whatsoever – the physiology is the same regardless of the language spoken by the person who is delivering the resuscitation.

Next, such skills as airway management using a bag-valve-mask, reading an ecg, or using a defibrillator, are not presently taught in medical colleges or nursing schools in low income countries.

Finally, no one country or language group should “own” the knowledge. The scientific studies on which the protocols are based, belongs to all of us, no matter where we reside on the planet.

Companions

I hate to sound like I’m only ranting, so here are some ideas:

Why not a companion set of goals for “Improving In-Hospital Response To Cardiac Arrest?” especially in low income countries.

What about convening experts in this area from Africa, and/or South Asia, and/or other regions, to discuss ways to address this based on a non-Eurocentric approach?

And finally, for Nepal – facing an epidemic of smoking-related cardiovascular disease. How can Nepal tap into this expertise to develop a sustainable system combatting this problem?

Summary

people in Nepal are working on these issues, piecemeal. Somehow Nepal gets left out of the discussion when trying to develop a “Global Alliance” – hey, Nepal is on the same globe as USA is……

That’s it for today…..

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