A break in the teaching marathon. ABGs in KTM.

My six-day teaching marathon is now history. Tomorrow is a day off, then two more days in which I will wrap up the fist of my five cohorts of students. There will be other similar weeks in which I teach every day but this was the first.

For student numbers I have:

Wednesday in the ballroom – 75;

LNC BN group – 15;

Bharatpur – 30;

Bhairawa – 30;


Orbit MBBS – 40.

As the juggernaut which is the big Wednesday group rolls further along, I have told the subgroups that I would schedule time to go with them to some of the hospitals. There are ten students from one specific hospital in Bhaktapur, and they reported that their hospital is eager for my visit, so I will have other activities in support of my efforts. Do I dare add a sixth compressed-course cohort to pick up those who could not get into the qWednesday event? And what about Bir, anyway?

Anyway, I am putting up some numbers. Making a splash.

So – yesterday with the fifteen BN students I queried the room asking “what is missing so far?” And by popular demand, people wanted to make sure I covered a class on Arterial Blood Gases (ABG).

Okay. Sure. One little problem, into how much detail should we go? The kids did not have much science background, these are PCL grads now getting a BN degree. Dilemna. How to do it without getting bogged down in remedial chemistry.

Straight to nursing application, and forget the chemistry. Be practical. Give “pearls of wisdom”.

So I focused on:

Physical assessment of impending respiratory failure (RF), coupled with definition of RF according to criteria.

Serial changes in P O2 and the concept of the “AADO2”. How to calculate.

Serial changes in PCO2, signs and symptoms of hypercarbia.

Then gave five emblematic examples of common ABG problems. Respiratory acidosis due to head trauma; resp acidosis due to hypercarbia; , metabolic alkalosis due to hypokalemia, metabolic acidosis due to DKA, and respiratory acidosis due to P.E.
The students did pretty well. They were blown away by the relationship between hypokalemia and alkalosis, and said that this had actually been an item on a standardized test they all took last year but nobody knew the answer then. It’s an elegant piece of physiology, after all, which addresses a frequently-occurring clinical phenomenon. This lends itself to a discussion of intracellular and extracellular lytes….. Yowzuh.

Now today we had a running joke, in which “whenever you wear a topi your IQ goes up” and at one point the student named Shanti answered ABG #5 correctly. I tossed the cap down the table in her direction – She beamed when she put it on her head – now memorialized on film. This is the kind of clowning around that happens when you have been together forty hours. But we were working effectively and the mood was light-hearted yet focused. I knew I had them with me the whole way. Love the days when that happens.

We did not do mega-code today. Spent afternoon time talking about mechanical ventilation modes. When I do much drawing on the board I like to give little questions to discuss. As the group does this I get up and look over their shoulders to see what they have been writing. A way to get feedback for myself. It’s also a time when those who speak better English can discuss the recent aliquot of lecture in Nepali with their less-bilingual colleagues, bringing them along. When I did the spotcheck, I could see that they all re-drew each of my diagrams and explanations into their personal notebook, actually very well. This type of meticulous note-taking has become a lost art in USA given the emphasis on PowerPoint and multimedia. Old School.

Whenever I discuss mechanical ventilation I always spend time on the idea of “phasing in”, even putting a theatrical emphasis on the mysteries of assessing “phasing in”. Here is an area where mysticism and critical care nursing intersect. I had the group “phase in” with each other, in pairs, using my method of zen. This assessment provides a critical interface between what the nurse does and what the RT does.

Also discussed the “V.A.P. Bundle.”

The discussion of ventilation allowed me to gain an idea of some of the typical practices in KTM Valley, surveying the class as we went along, regarding current general practice. No need to re-lecture in cases where they already have experience…. There is wide availability of ABG; they do use CXR when needed; CPT is available and they all know how to do it; weaning strategies are similar. The one area which I think needs a general upgrade is the practice regarding care of suction catheters. It is routine practice to re-use these, storing in a bottle of saline. This practice has always annoyed me, but is economically justified (sort of). I told them at the very least, they should add vinegar to the solution, as USA nurses sometimes do in home care. (Need a reference on this- I do want to follow up – the ideal is to use a new catheter each pass, but in the interim, changing the soak solution is a good step – can anybody out there help?). This simple step would prevent a lot of VAP, IMHO.

We discussed sedation strategies. BTW the customary drug here at time of intubation is midazolam, 3 mg IVP.

Yep, that’ll get ‘er done!

Then to weaning. For the life of me I couldn’t recall the name of the post-op recovery assessment scale used to score extubation. Oh well, I am destined to get old some day….. Lucky I still have a full head of hair….. I won’t consider myself old until it all turns silver….

After lunch they were teasing me about everyone being drowsy from a bellyful of rice…. So I asked them to put their heads down and pose for a photo – now posted on FB.

A good vibe all around.

We had fortyfive minutes of thunder and lightning yesterday. At the beginning of monsoon, this will happen… The expectation builds, but it was just a tease and the rain did not begin.

One previous time the actual onset of monsoon was heralded by the most dramatic such weather I’d ever experienced, and when it came there was dancing in the streets of Tansen. In the meantime It’s a tad dusty here.

Almost forgot to mention that the doc from Orbit MBBS came by, first thing in the morning. Good side discussion about teaching an ACLS cohort with his group of MBBS docs. Looking more definite. I am thinking I will leave the ACLS course materials I brought, with him as opposed to LNC. There does not seem to be anybody routinely teaching ACLS here, according to him. Or BLS for that matter. The docs need this too!

Saturday 11 of June, I do not teach. It would be great to get out of dodge. I wanna take the bus to Bhaktapur. Then get a taxi to Changu, the ancient World Heritage site on the ridge. A sweet little Newari town just below the mandir. And then perambulate the downhill route from there back to Bhaktapur. This is about a three hour walk, extremely picturesque. Traverses a hillside network of wonderful terraced rice paddies. Last time I did this hike the townspeople were ankle deep, planting, babies on their backs, and you could take in the ancient rhythmical wonderment of rice cultivation. Culminating with entry into the fabled Malla kingdom…… Famous for the quality of dahi made there….. Best I ever ate….. Mouthwatering to contemplate.

One of the epic short hikes of KTM valley.



About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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3 Responses to A break in the teaching marathon. ABGs in KTM.

  1. gaynor says:

    Hi Joe, in regard to suction catheters, I took to Tansen some of the multiple use “inline” suction catheters we use in our ICU’s in Australia, to see if it was possible to use them instead of the single use ones. I too was concerned at the way they were being re-used and stored. The inline suction catheters have lots of advantages in terms of preventing VAP, plus suctioning then has less impact on oxygenation/ventilation. A major factor in an unstable patient. Obviously cost is the big issue but the inline suction catheters probably don’t need to be changed as often as they are here (we change every 24 hours but this could easily be extended) . Maybe the bigger hospitals could source from India and get a reasonable deal? May work out cheaper and would certainly be cost effective in terms of health outcomes/length of ICU stay with VAP etc. Our friend at Tansen was looking into designing a metal connector to do a similar “inline” thing using the usual single use suction catheters but not sure how far he got with that!
    When I taught ABG’s at Tansen I went into even less chemistry (not a strong point even for me) and more practical nursing application. I used a number of case studies where the students had to decide on ventilation strategies in response to different ABG results (which they had to interpret first of course) and vital signs. They were simple case studies but seemed to work well in bringing it all together.
    By the way, I worked out RT but I think you may need to translate some American abbreviations for me – CPT? Hope your day of R and R is going well. Gaynor

  2. Lorraine says:

    Regarding “old school,” I think we actually learn better that way. At least, its true for me. When I’m taking notes by hand, the information seems to stick better than the current method of powerpoint & such. It sounds like you are having a great time and passing along much needed education there. Its obvious that you truly love teaching. Me? I’m looking forward to getting away and not having to think about nursing! I do plan on bringing some books to donate. Whatever books I can pack up to 20 kg! Your walk from Changu to Bhaktipur sounds wonderful. I’ll have to do that one too!

  3. I got lost on the hike. Well, not exactly lost; but the route turned out to be sifferent than I planned. A metaphor for life……Today was a day for some contemplation time, which was valuable…. “If I forget to praise thee, Lord”.

    I am feeling good about things, this has been due to a lot of planning, as well as excellent hosts at LNC, but I have to remind myself not to get arrogant about it.

    I wonder as to the degree to which I am the actual beneficiary of God’s grace this time around, and when that happens you have to acknowledge. I have received so much help and support along the way! There is a long way to go before this is complete. I need to keep learning as I go along.

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