CCNEPal – 2011 to 2019
Greetings. you have found the blog of CCNEPal, a sort of pseudonym I used when I travelled to Nepal to teach. Over the course of years I chronicled my trips and wrote about the challenges of doing critical care in a low resource setting. There are about 250 blog entries here. Feel free to browse. If it is photos you want, go to the accompanying FaceBook page. I tried to share things I learned in case any other foreigner wished to go on a similar quest to any Low Income Country to conduct training.
It’s time to reflect on the entire trajectory since I did not go there in 2020 or 2021, and unless something radically changes I do not expect to go there in 2022. The pandemic has forced me to reconsider those plans. I wish only the best to all the people of Nepal and South Asia and all countries, but the torch of excellence in critical care is being passed to a new set of players. I think I did the best I could to carry out a quest which was Quixotic at times. Therein lies a tale.
2007, 2008 and 2009
I actually made three trips to Nepal before deciding to focus on critical care and the grandiose plan of changing the perception of the value of such a service. Though I had been a nurse for decades I had not really travelled outside USA much. It had been a lifelong desire to visit India and the Himalayas, and the circumstances lined up to allow me to go in 2006, so I began to plan the first trip.
I contacted United Missions to Nepal and arranged to teach nursing in their PCL program in Tansen, Palpa District. Tansen is a small city in the hill country, and Mission Hospital has been there for around fifty years. It attracts a small community of videshi medical personnel who provide mutual support while offering their skills. It was an ideal place to start learning about Nepal healthcare due to this factor of having a peer group. Many of these persons were quite colorful.
What I learned in Tansen was that the status of critical care was low. Not just in Tansen but throughout the country. There were severe deficiencies in traning and practice. This was not a reflection of Mission Hospital per se, but an outgrowth of decades of priority-setting in which a very utilitarian approach to allocation of resource was followed at most levels. I think I was careful not to present myself as “the kuire expert from away” and to respect the challenges of delivering care while there, but I couldn’t help from seeing examples of excess deaths in the acute inpatient care, due to the way things were set up. I would followup by discussing things with the people around me and there was always an explanation for why it had to be the way it was.
“We only have a fixed amount of money and we need to spend it on areas where it will serve the greatest number of people.”
“‘Our Priorities are infectious diseases, maternal-child health, and public health in general. It’s foolish to focus a lot of money on a small population such as would be candidates for critical care in the west”
In the first year in Nepal I even met a nurse in Kathmandu who was a consultant in nursing ( a Nepali person) who told me I was wasting my time thinking about how they could do better at critical care and it wasn’t needed. In the second year on a teaching trip outside Kathmandu Valley I met a senior doctor who told me that it would be impossible to teach any nurse in Nepal how to read an ecg strip. The mindset was pretty firm.
The first summer in Tansen ( I tended to go only during summer vacation from my University teaching job), was a shock to me. I spent the following eight months trying to recall if anything really actually happened the way I remembered it, or if I was somehow exaggerating past events out of proportion. This sense of puzzlement led me to return in 2008 and 2009. I think many other videshi persons would not have done so, chalking their time up to experience; but I could not move on after having done it the first time.
Outgrowing Palpa District
On subsequent trips I contemplated the idea that Nepal has thirty million people and the one hundred sixty bed Mission Hospital in Palpa district was not going to be a place from which I could make any kind of large impact to teach critical care. So I started to develop contacts with people from other parts of the country, especially Kathmandu the capital. In summer of 2010 I stayed in USA to spend time with my daughters, then returned to Nepal in 2011 with the idea of CCNEPal.
My new home base was Lalitpur Nursing Campus, considered to be the best nursing school in the country at that time. It was still within the archipelago of former projects of United Missions to Nepal and they were used to hosting foreigners. For a nominal fee I could use their largest classroom. The campus of LNC was housed at a former Rana-era palace and it turns out that the largest classroom was the former ballroom, replete with red velvet curtains on a small stage, colorful decor and a large crystal chandelier. I taught four or five sessions of an elementary critical care course, and also took my first trips to Bharatpur and Bhairawaha to teach in Terai. And we were off to the races!
There was a very small community of doctors doing critical care in Kathmandu in those days. The Nepal Society of Critical Care Medicine had been formed, but they were small and limited to Kathmandu inasmuch as they did not see themselves as having a national vision that I could tell. This was before the return of Subbash Acharya from Canada where he had done a fellowship in Toronto. The NSCCM did not give much thought to the training needs of nurses in those days. At the time I was dismayed that they too had tunnel vision as to the possible benefits of developing a robust approach.
The first courses were specifically for nurses in Nepal. I got excellent “word of mouth” and the participants were quick to recognise the value of what I was teaching, often returning to their hospital to lead critical care services and tell others about me. A ripple effect began. Soon, I was busy teaching two three-day short courses per week when I was there, travelling throughout the country, and developing relationships. This included more time in Terai, the hot southern flat region bordering India. I began teaching session to MBBS students and Medical Officers.
Over the period from 2011 to 2019 I taught 125 sessions of my course, giving certificates of completion to more than 4,500 nurses and doctors. The knowledge was becoming more widespread. My “word-of-mouth” reviews continued to be excellent. There had been pockets of medical knowledge in this area around the country and those places didn’t need help from me, but the training led to higher standards in parts of the country where they were too far from Kathmandu to get their knowledge from there. One unexpected side-effect of teaching critical care was that I also taught de-escalation techniques to minimize the likelihood of “thrashing,” a related problem. I worked hard to identify specific obstacles and continued to tweak my training as I learned more about specific needs.
During that same period, Dr Subbash Acharya of TUTH became the driving force behind NSCCM. He worked tirelessly to create and enlarge the community of expertise in Nepal, and helped establish the Nepal Association of Critical Care Nursing. Also, I helped organize the first American Heart Association International Training Center for ACLS, run by the Laerdal franchisee Center for Medical Simulation ( CMS), and they started teaching ACLS on a more regular basis year-round.
Those who wish to have more of a blow-by-blow recounting of events will find more detail in the past blog entries. We are now in the midst of a worldwide pandemic of covid-19, and Nepal is among those countries that have undertaken efforts to strengthen critical care. Obviously the first step is to purchase specialized equipment, but we still need to train staff in specialized skills, and this is now ramping up.
There is so much to say about the time I spent, the learning that took place, and the progress that has been made. Permit me to be smug for just a minute here. All the things I said after my early trips to Nepal have been shown to have been necessary for the advance ment of health care there, and there is a much stronger voice for the teaching and practice of critical care skills, than had existed when I started. Obviously, I was not the only person invloved in this progress. I normally don’t blow trumpets and beat a drum to say how wonderful I am – far from it. But I think I did make a difference with this project.
There are many people ( Nepali and videshi both) to thank for all the time there and the successes we had. Perhaps too many to list. Perhaps hundreds. If I could line them up, I would give each a kata scarf, a marigold garland, and a tika. I like to visualize smal tokens of gratitude in that way but the actuall doing of such a ceremony would take days – so let’s just call it good. I personally have been enriched by getting to know so may truly dedicated people working against heavy odds to help their fellow human beings. I have loved learning about Nepali culture and I like to think I now a world citizen in a way I would have never contemplated if I had not spent the time there.
In the past I mostly contribute to this blog when I am actually in Nepal. I may still write here from time to time, but I don’t know when. Until then, best wishes to everyone!
PS I will publish this today and edit it periodically to add URLs, photos and the like.