Join CCNEPal summer 2018 to teach critical care skills in Nepal

Interested in using your skills in an international setting for global health?


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….

……. but don’t have any contacts or  know where to start?

You are invited to contact CCNEPal and see if we are a fit for you for summer 2018.

We are looking for American RNs or MDs with acute care background who can help teach critical care skills to nurses and doctors in Nepal.

Time commitment: at least one month summer 2018.

budget: all expenses are borne by the participant. These typically include airfare $1500; fooding and lodging while in country ( $400 per month). tourist incidentals.

Locations: we expect to spend a bit of time in Kathmandu, the capital city, at the beginning and I will be happy to show you around. We spend time teaching in Kathmandu, but also in the Terai, the southern plains. This is not a picturesque experience distributing toothbrushes in some Sherpa Village in the Himalaya.  If the location is not populous enough to support a medical college and teaching hospital, we don’t go there. Read past blogs to get an idea of where we go within Nepal.

That’s it. We will help arrange things, but we don’t charge a fee to cover some mysterious and unspecified administrative costs. CCNEPal is a shoestring operation, we expect each participant to provide their own health insurance and incidentals.

What we are looking for:

Nurses and doctors with a open mind, a sense of humor, and the willingness to work hard. This is not a party experience in any way, and I need to say upfront that if you need to have alcohol to get through the day, this is not for you. (um, caffeine is another matter. I know every source of “Organic Coffee” in every city I have visited). (instant coffee is an abomination).

What it is not:

It’s not for new graduates who do not have a solid core of acute care experience. The students can tell whether you know what you are talking about.

It’s not a sightseeing trip or party opportunity. You don’t have to work six days a week like I do (and like the Nepalis do) but there will be a full schedule of teaching in your topic arranged by our partners with full classrooms. In 2017 I taught 365 people in six weeks. you do the math.

It’s not a wander-in wander-out experience for international vagabonds with a nursing degree who wish to add Nepal to their bucket list of countries. You would need to submit a CV, letter of interest, and some references in addition to engaging in country-specific preparation.


In Kathmandu mid-morning chiya and biscuits are just the thing. Before the CCNEpal project is through, we will consume one million cups of chiya and two million biscuits. and I always ask the participants to toast – they toast the previous groups and the future groups. ( note: a few people got nescafe – OMG!)

It’s not a stay at a nice hotel with a pool. We might occasionally splurge but we mostly stay in the kind of lodging the Nepali people would favor, and we eat the local food. Don’t come if you don’t like rice.

Content and approach

We use specific teaching methods to offer a two- or three-day course in critical care skills loosely based on the AHA ACLS class (though it is emphatically NOT associated with AHA nor does it lead to a USA ACLS card). So, first and foremost we are looking for nurses who are willing to study our pedagogical approach to ACLS-type training, and teach the workshop. We don’t use PowerPoint, we don’t distribute mountains of handouts, and we don’t rely solely on lecture. We are highly practical and interactive.

We have had many inquiries to teach other courses. First, some kind of one-day workshop on nurse’s responsibilities for the mechanically ventilated patient; and second, a course in recognizing pediatric emergencies.


If you are certified to teach these, we would especially like to hear from you. There is tremendous need for these two specific courses. Similarly, ABLS (Advanced Burn Life Support).

American Heart Association

As stated above, what I teach is consistent with the latest standards of the American Heart Association, but for a long list of reasons, this is not the “official” course. Having said that, if you are qualified to teach the official course, I can forward your name to the one-and-only AHA International Training Center in Nepal and you can plan to teach with them.



Dal-bhaat deluxe. Rice with lentil soup is the mainstay of Nepali diet.

Nepal is not an easy country for your first international experience, and Kathmandu is not an easy first international city, if you have never travelled.  Study and preparation is needed and it is important to begin months in advance. You will not be “parachuting in” – you would be working with local contacts in the health professions education sector with whom I have had working relationships for more than five years (in most cases).

About Language (and culture)

the main language of instruction in medicine and nursing in Nepal is English. However, there are many cultural nuances important to Nepal and it is helpful to study those. Even to know a little Nepali before you go, is a good idea.

This experience is ideal for a graduate student with the time to prepare. Browse through this site and related links, then give me a call.



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Report of Summer 2017 CCNEPal sessions in Nepal


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

Packing up for a long flight

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

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

We taught 77 nurses at Lumbini Medical College in Palpa.


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

fifty nurses at Chitwan Medical College, Bharatpur

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

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


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

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

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

twentyone Medical Officers at Norvic.


The total seems to be 364 participants.


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

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

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



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

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


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

Future Plans

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

Building Community

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

Picture 443

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


one of our youngest patients

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

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

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


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

Terms and conditions

the deal would be:

You would pay your own airfare.

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

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

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

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

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

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Revised Schedule for Summer sessions of CCNEPal 2017

Three weeks shortened from end of schedule

Updated June 24th

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

Here are the remaining sessions:

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

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

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

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

I fly out at 0815 July 2nd.

Attitude of Gratitude

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

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

Use the minimal-leak method instead. Described below.

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

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


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

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

Continued next page

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

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

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

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

 Stethoscope

 Cuff pressure manometer

 Three-way stop cock

 OR Cufflator cuff inflation device

 Manual resuscitator and mask

Step Action
1 Technique for MOV

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

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

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

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

Here is a video showing exactly how to do it:

What if you use too much air?

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

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

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

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

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

Where: Sociology Department, Tribhuwan University, Kirtipur, Nepal

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

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

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

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

For further information, call 98010 96822

or email

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about mechanical ventilator patient in Nepal

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

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

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

The Snake Man

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

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

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


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

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

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

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

The Pen Drive

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

On the internet I found:

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

Here are some video links I liked:

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

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

Minimal Leak method

Cuffed ET tube

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

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


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

Phasing in

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

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

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

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