July 6th 2018 Update for CCNEPal


UPDATED July 13th

This will be brief.

we now have about two weeks remaining on this trip. We have taught seventeen sessions and given 489 certificates. We will give about a hundred more if all goes to plan.

Valerie Aikman,RN, BSN has been a wonderful addition to the CCNEPal team, offering a level of consultation on nursing issues I was not able to do in the past. I will write more about her in the future. She will most likely write some guest blogs.

Calendar:

July 15th, 16th, 17th Narayani Samaiyudak, Bharatpur. We will work with a very longtime colleague, Dr. Kalyan Sapkota. This will be a three-day session and include nurses from the District Hospital here.

July 18th, 19th and 20th – one last 3-day session at College of Medical Sciences. for nurses. We have truly enjoyed our collaboration with College of Medical Sciences, and we are discussing how best to work together in future.

mugling road landslide

July  21st – return by airplane back to Kathmandu Valley.  Since monsoon there are more landslides on the Mugling-Narayaghat highway. Since my bus accident a few years back I plan the travel so as to take the fewest bus trips possible. Therefore, a plane ticket. We did take one bus from Janakpur to here.

July 22nd, 23rd and 24th CIWEC Clinic in Kathmandu.

July 25th, to Aug 2nd – open dates. we will meet with supporters and friends in Kathmandu…  time to “stop and smell the incense” and there are many persons we wish to meet with before we leave so as to set things up for next year.

August 2nd – rendezvous with TIA for flights to USA.

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CCNEPal 2018 updated schedule as of June 9, 2018 “On the trail to six hundred certificates”


This is the updated itinerary for CCNEPal as of June 9 2018.

We have taught six sessions since arrival, with 179 certificates given. We will do two more three-day sessions this week in Kathmandu, at Mediciti Hospital. Mediciti has been a wonderful host and I love the staff there.

At this rate we will train about 600 nurses and doctors in Nepal this year. We already trained 3,200 in past visits.

“This is not like other training”

I get similar feedback from every group. “Nobody told us what to expect, so I thought it would be one more lecture day by a videshi using all PowerPoint and many handouts. It turns out to be very practical and hands-on.”

Anybody can teach the drugs, how to do CPR, and read an ecg.

Not everybody can teach confidence, teamwork, poise and how to think under pressure.

I lie to think we are transforming the way people look at their role in critical care, and soon I will expand this idea in another bog. Not today, though.

Next Stop

We travel to Terai June 16th, by plane to Janakpur.

June 17th,18th and 19th, then 20th, 21st and 22nd. – two 3-day sessions at Janakpur. This is also a return visit. In 2016 we worked to develop ICU staff there. I am pleased to report that JHCRC is  now offering a full range of critical care services, such as thrombolysis. We expect to focus on schools of nursing there, to ensure the supply of nurses. This will be Valerie’s introduction to the Terai.

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I asked to take a photo and the shopkeeper got a new vat of yogurt out of the fridge. the yogurt here is every bit as good as the fabled yogurt of Bhaktapur!

Travel day June 23rd. long distance bus from Janakpur to Chitwan.

June 24, 25 & 26th – College of Medical Sciences (COMS), Bharatpur.  Nursing 3rd years. Also known as “Purano.” This first session will be for nursing students. COMS is a location I visit since 2011. Because it is a major teaching facility, people trained here disperse throughout the Terai region.

June 27th, 28th and 29th – College of Medical Sciences (COMS) a second batch of nursing students.

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

July 1st,2nd, 3rd COMS – a batch of staff nurses.

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CMS Nursing College in Bharatpur enrolled their thirdyears in the CCNEPal 3-day class. They were really good.

July 4th, 5th, July 8th & 9th, July 10th & 11th – three 2-day sessions for Medical Officers and interns at COMS. 

July 12th, 13th and 14th – Maybe time to go to Chitwan National Park so Valerie can ride an elephant and feed a tiger. My personal favorite in that location is the river trip in a dugout canoe to observe wildlife, mainly birds.

July 15th, 16th, 17th Narayani Samaiyudak, Bharatpur.

18th, 19th and 20th? possibly another session in Bharatpur, who knows!

July 22nd through 27th – this is the only remaining week to be booked with teaching or consulting.  We can do two three-day sessions (for nurses) or three 2-day sessions(for MBBS). We have passed emails with various hospitals in Pokhara and western Terai but nothing is confirmed. If any body reading this wishes to host a session or two, please contact me at joeniemczura@gmail.com

July 28th -return to Katmandu

August 2nd – depart  Nepal for USA.

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June 9 2018 update on anatomy lab for our training course on critical care skills


The first session for this year’s series of training programs in Nepal was held at National Trauma Center, part of Bir Hospital, for a group of BN nursing students. One member of the class had previously taken the course and asked if I was still doing the anatomy lab.

I used to always make time for this and in fact, a picture of two gloved hands holding a heart serves as the profile pic for CCNEPal FaceBook page.

These days? well, no, I haven’t been including it.

Why not?

There was no good answer, so – we enlisted various class members to  go to their local fresh shop and find “en bloc heart and lung assemblies” – and we had an educational time that revealed many secrets of the heart.

I wrote about this five years ago, and here is the link: https://wp.me/p1pDBL-fp

We are now at a large Kathmandu hospital where we are training four batches of nurses with thirty people in each. We are including the lab in all four sessions of the course.  The use of this material of to advance scientific knowledge, and the goats would have been harvested anyway. In fact, the lungs would have been fed to neighbor dogs. There is a nearby fresh shop that supplies five each time, one for each group of six students.  Enough to allow each student to get a close look.

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We make a systematic tour of elements of the heart, lungs and trachea, finding such things as the pericardial sac, the valves and the coronary arteries. No matter how well the teacher can draw, there is no substitute for seeing the actual structure. Each nurse who participated will now make better physical assessments of their human patients because of the knowledge they gained.

Here is an example from YouTube that shows one way to do the dissection. https://youtu.be/XH4K4b0N_Yw I think it has the info, but I don’t lead my own labs that way – she’s is a bit passive, doing all the handling herself. It’s more fun to make the students handle it themselves and discover it for themselves.

Not wasting anything

One thing to point out: when we are finished I end up with about eight pounds of organ meat. I don’t simply throw it in the trash. I take it home and recycle it. Each set of heart & lung gets cut into small pieces. I bring it up to the roof of the Guest House for the crows to enjoy.

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I do not waste the flesh or put it in landfill. As many as three dozen crows swoop in to take morsels back to the nest for their young. There is one day per year in which crows are venerated on the Hind calendar.  This batch of crows is getting food every day for two weeks.

The crows get excited when they see me climb the spiral stairs to the top patio.

The One Mystery

So far, no group has been able to identify the structure of the heart from which True Love emanates. We will keep searching.

 

 

 

 

 

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CCNEPal itinerary for #Nepal critical care teaching summer 2018, places and dates


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At Bir Hospital school of nursing, the B Sc program is for nurses who completed PCL then have worked for two years. The focus of education there is to improve medical-surgical nursing and they are keenly interested in critical care. I was there last year and the students were excellent. The “five assistants” are shown, wearing the distinctive uniform sari of Bir.

We arrive May 17th (Joe) and 19th (Valerie) and run around like crazy getting supplies and things organized for a couple of days. Wish us luck!

The schedule is falling into place

May 20th,21st and 22nd – Bir Hospital B Sc students. These nurses have completed their PCL nursing and are going for the B.SC. degree. Bir is government-run. It is the main teaching hospital for NAMS, the National Academy of Medical Sciences, and serves as a free-of-charge resource for people from all over Nepal. Located right on the edge of Old Kathmandu. This is a return engagement for us.

May 23rd, 23th and 25th Bir Hospital Trauma Center staff nurses.

May 26th holiday and recuperation

May 27th, 28th and 29th – National Burn Center staff nurses, Kirtipur

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The “HDU” at Kirtipur is the most active critical car unit for burn victims in Nepal. This will be our second trip to teach there.

May 30th and 31st National Burn Center Kirtipur, interns and Medical Officers (2-day)

June 1st and 2nd holiday for two days – r & r

June 3rd, 4th & 5th – Meditici 3-day #1 session. This is a new facility just outside the Ring Road in Lalitpur.

June 6th, 7th and 8th – Mediciti 3-day,  #2 session.

June 9th – travel day. From Kathmandu to Janakpur. This begins the Road Trip through Terai.  Most likely we will fly there. My first trip in 2016 was memorable and epic.

June 10th,11th and 12th, then 13th, 14th and 15th. – two 3-day sessions at Janakpur. This is also a return visit. In 2016 we worked to develop ICU staff there. I am pleased to report they are offering a full range of critical care services, such as thrombolysis. We expect to focus on schools of nursing there, and we have yet to determine whether we stay an additional week. It depends on the demand for training and also whether we will add a PALS course, etc.  specific breakdown TBD ( combination of 2-day and 3-day sessions)

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I asked to take a photo and the shopkeeper got a new vat of yogurt out of the fridge. the yogurt here is every bit as good as the fabled yogurt of Bhaktapur!

Travel day June 23rd. long distance bus from Janakpur to Chitwan.

June 24, 25 & 26th – College of Medical Sciences (COMS), Bharatpur.  Nursing 3rd years. Also known as “Purano.” This first session will be for nursing students. COMS is a location I visit since 2011. Because it is a major teaching facility, people i train here disperse throughout the Terai region.

June 27th, 28th and 29th – College of Medical Sciences (COMS) a second batch of nursing students.

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

July 1st,2nd, 3rd COMS – a batch of staff nurses.

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CMS Nursing College in Bharatpur enrolled their thirdyears in the CCNEPal 3-day class. They were really good.

July 4th, 5th, July 8th & 9th, July 10th & 11th – three 2-day sessions for Medical Officers and interns at COMS. 

July 12th, 13th and 14th – Maybe time to go to Chitwan National Park so Valerie can ride an elephant and feed a tiger. My personal favorite in that location is the river trip in a dugout canoe to observe wildlife, mainly birds.

July 15th, 16th, 17th Narayani Samaiyudak, Bharatpur.

July 18th,19th 20th open, any session needs to be in Bharatpur.

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(my photo) Rush hour in Sauraha, next to Chitwan National Park. This is what the tourists see. Most cities do not actually have these.

July 22nd, 23rd, 24th possible Danghadi. tentative, CCNEPal has never been further west than BTWL, it’s about time don’t you think?

July 25th, 26th, 27th possible Dangadhi at Zonal Hospital.

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The “standar5d class size” is thirty. Five are asked to be “assistants” ans then five groups of five each. So, we need five sets of the flash cards! They are colorcoded. Each assistant gets a laminated list of the possible scenarios we will eventually be doing……. this system is impervious to loadshedding.

Subsequent dates and locations tentative, will be announced as they are booked.

July 28th, travel day. We will disappear from one location and re-appear as if by magic, hundreds of miles away. Here is a short video that explains how this is done:

July 29th, 30th, 31st – one last session in Kathmandu. Historically, CCNEPal has always offered a few first-come-first-served sessions in Kathmandu, and we have been reminded that this year’s schedule has not allowed room for such trainings.

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Pediatric Life Support course: we have yet to schedule these sessions, stay tuned.

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.

Return to Kathmandu the week of July 29th.

Fly out back to USA August 2nd.

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Teaching #criticalcare skills to nurses and doctors in #Nepal, getting ready for summer 2018


Summer break. School in USA goes for one more week. Then in two weeks, CCNEPal gets on the plane for Nepal again, teaching critical care skills for summer 2018.
What does CCNEPal do, exactly?
This has been answered on the blog you are reading, right now. Since 2011 I wrote more than 262 entries here. We do a 3-day course for nurses and 2-day course for MBBS docs.  I write less when I am in USA and more when I am in Nepal. I have taught 110 sessions of this since 2011, awarding 3,200 certificates. I  can easily supply a list of references from Nepali hospital administrators, doctors and matrons who have hosted me.  There is also a FaceBook page that supplies plenty of photographic proof as to where I have been and what I have done.
You can also check out my YouTube channel, here is an old video that shows my teaching it’s 24 minutes but still a good representation of the spirit. https://youtu.be/FZjqfOdWRb8
here is a shorter video that shows the class members practicing megacode. it has a narrative that shows how we divide into groups that get the entire class involved: https://youtu.be/HCQmdtmmKVo
I do teach how to defibrillate: https://youtu.be/pp39rHm2fJI
In ten words or less, I teach a highly modified version of a ACLS class over the course of three days. We start with CPR but quickly go to team dynamics, how to conduct yoursel fduring an emergency, ecg, defibrillation, and the ACLS protocols. On the final day we also address issues of situational awareness to employ to prevent and mitigate “thrashing” when tension is high.
to read about what I need for a classroom, go here: https://wp.me/p1pDBL-1mk
here is the outline for the 2-day course we teach MBBS docs : https://wp.me/p1pDBL-to
we are highly scenario-based, and here is a list of the scenarios: https://wp.me/p1pDBL-tZ
here is a blog entry that describes how we teach situational awareness using role play: https://wp.me/p1pDBL-Bb  
New Team Member
This year I am pleased to announce that Ms. Valerie Aikman, RN, BSN will be joining me. Ms Aikman has a background in critical care management. She will add some unique skills to the project. In USA she works for a company that consults with hospitals regarding critical care, and she works as an “interim manager.” Typically, she goes to any given location for two or three months at  time and runs the ICU when the hospital is looking for a permanent ICU manager. Not only does she love to problem-solve and consultate (is that an actual word?) but she is good at it. She has always wanted to travel in Nepal and see what hospitals are like. She has a background in Er and Trauma ICU; I often get asked if I teach a mass casualty triage course and now? we can! She is a wonderful addition to our team.
Schedule of courses
We will be teaching two 3-day sessions at Bir Hospital starting May 20th, one for the B Sc students and one for staff nurses.
then a 3-day (nurses) and a 2-day ( doctors)  at the National Burn Center in Kirtipur
then 3-day courses at Mediciti Hospital in Lalitpur. We have confirmed one week, we may add a second week.
After that we will go to Terai, where will teach at Narayani Samaiyudak, College of Medical Sciences, and Janaki Health Care and Research Center in Janakpur ( two weeks).
Usually we offer some first-come-first-serve open to all comers sessions. We will plan to return to Kathmandu and announce some of these in late July.
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April 21 2018 Update on CCNEPal summer trip to Nepal


The ticket(s) have been purchased.

CCNEPal is (usually) a one-person circus of teaching and we never know whether any given trip to Nepal will be the last one. I have been saying this since 2007, the first year I visited Nepal, that “I don’t think i will ever do that again” – and yet, I do.

Nepal is a bigger country than you think

I am a volunteer, and I always am amused when I meet some other medical person (usually a young MD) and they tell me “Oh, soon they won’t need your training any more; I’m here in Nepal and I am training them how to do critical care. ”

Yes, more than one person has said something like that to me. So, I ask for more detail. Then they say, “I’m here for two weeks and I will work with a dozen people.”

Nepal has 30,000,000 people, 22 medical colleges, hundreds of nursing colleges, and many cities outside of Kathmandu Valley. There are seven medical colleges in just the Kathmandu Valley, and a government health bureaucracy as well.

So, more training is needed to ramp things up. A lot more. Um, I trained 3,200 people in many regions of Nepal over 110 sessions during a ten year period. And we are still getting up to speed. I am happy to say that more Nepalis are stepping up and teaching it themselves, which is the way it should be.

To get ready this year I spent $$$ buying teaching materials for ACLS and PALS.

acls instructor package 2015I always teach as much of the latest protocols as I can, though the American curriculum needs to be adapted to reflect things like the availability of drugs and equipment. I get the protocols from the American Heart Association and this year I got all the bells and whistles – the complete “Instructor Package” including books DVDs and posters.

pals instructor package

I also bought the stuff to present the latest Pediatric Life Support standards and protocols.

I have been updating some of the key handouts from my “usual class” so they make it easier to run each course.

Schedule

I will arrive in Kathmandu the 17th of May and begin the first session the 20th, at a major school of nursing in Kathmandu, one where the students come from all regions of Nepal and will return home after their degree. I will be teaching in Kathmandu for about three weeks, during which time we will award about 200 certificates.

After that I get on the bus to Bharatpur, where I will spend two weeks. I am not sure what to expect on the Mugling-Narayangarh road!

mugling road landslide

the main road from Kathmandu to the outside world goes through a spectacular river canyon and has been under reconstruction since the Dawn of Time. Lots of twists and turns. I try to minimize trips on this road. 

I will spend a week teaching in Janakpur also while in Terai.  If you wish to host my training, read this previous blog entry on what is needed. This requires a large classroom and at least 30 learners.

Colleague with a Secret Identity?

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Nurses never bring attention to themselves. My colleague is carrying on in the finest tradition of selfless secret identity. 

A person with extensive experience managing ICUs in USA will be with me, and I will do a blog introducing her soon. She is a USA RN with many years of experience who wishes to share her expertise with her Nepali peers. For now she will be a “mystery person” – isn’t it cool to travel with somebody who has their very own secret identity? Here is the first clue as to who, exactly, she may be.

 

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Doctors thrashed by mob of fifty people at work in India, after death of 26 year old man, March 20th 2018


Okay, so I use this blog to keep a running track of “thrashing incidents” in Nepal. I also list incidents in India since this problem is worse there. Today’s news was about the actual death of a resident doctor in India.

https://timesofindia.indiatimes.com/city/pune/relatives-assault-doctor-after-death-of-patient/articleshow/63447556.cms  

PUNE: A resident doctor was assaulted with a scalpel and a few paramedics were roughed up by relatives of 26 -year-old man after he suddenly died following a cardiac arrest at D Y Patil Medical College and Hospital in Pimpri late on Friday evening.
The resident doctor suffered a deep cut on his face and some blunt injuries in the assault. The hospital management on Saturday filed a complaint with the Pimpri police.

The doctors demanded strict implementation of the Medicare Act, 2010. It protects them from physical assaults and intimidation by patients’ relatives. These acts are non-bailable offences under the act.

A doctor of the hospital said, “After we broke the news of patient’s demise, the relatives burst into rage and barged into the ICU (intensive care unit). One of them took a scalpel and slashed it on a resident doctor’s face claiming negligence. Others joined him.”

Another resident doctor said, “A local politician claiming to be a policeman hoodwinked the security and entered the ICU, where quite a few critical patients were undergoing treatment. He arrived with some supporters within 10 minutes of the event.”

After entering the ICU, they proceeded to assault the men and women doctorsl. “Fearing for their life, these doctors are wondering if they should even go to the police,” the doctor said, requesting anonymity.

The securitymen of the hospital failed to prove their effectiveness during the assault. “The bouncers and security guards employed by the hospital stood back and did nothing. They have been identified and would be dismissed,” said another doctor.

There was some communication gap between the hospital’s senior and middle management. “The middle management did not inform seniors about the scenario. They were afraid of being found out for hiring a bad security agency,” said another doctor.

The hospital’s dean, Jitendra Bhawalkar, said, “We always stand by the side of our resident doctors and ensure that their protection is never compromised. We have filed an FIR with the police in this regard.”

 

Photo

The incident was also reported at: https://punemirror.indiatimes.com/pune/crime/deceased-patients-kin-attack-doctors-at-dy-patil-medical-college/articleshow/63447514.cms

News reports included a photo of the injured doctor, showing the injury with the scalpel. It was very graphic. Originally, I decided not to post it here, which turns out to be a good thing since the graphic photo was from a different person altogether! Also, the viral meme on the internet shouted the news that the doctor had in fact died – this needs to be verified.

CCNEPal training

If you are new to this blog, please read previous entries on the subject of “situational awareness” and thrashing of doctors. CCNEPal was originally started to provide better training of nurses and doctors in Nepal in the area of resuscitation after cardiac arrest. Soon after starting in 2011, we recognized the idea that the potential for being thrashed if things don’t go right was a major barrier in success. So, we teach about ways to identify a bad situation in advance and deal with it.  We expect to be back in Nepal in summer 2018 to train more personnel and raise awareness of this issue impacting medical care.

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