Bhairawa side-trip day two – not on the weather channel

Rickshaw part one

Didn’t actually leave the Guest House until 0700, left my A/C room and stepped out into the hazy languid mugginess that is the Terai. Immediate bath of sweat. A beautiful flutelike sound of a bird I could not see. Decided to leave the laptop in the room and travel to UCMS with just the orange bag. Packed the topi and wore the slouch hat, touristy though it may be. Took the short walk down the street to get a rickshaw and away we go. It’s a pleasant twenty minutes, time to process the sights as they unfold and then recede. It seems an experienced rickshaw driver will make adjustments for such things as subtle changes in grade, or certain-sized potholes. A quick cup of chiya at a kitchen outside the UCMS gate, and a handful of diwwali, those little sweet crunchy pretzel things. Not my usual breakfast. I have gone two days now without coffee. The chowkidars here salute as I go through the gate. I can see knots of women sitting together in the grassy shade of trees, bright saris of every color and design.

What to leave in and leave out

Entering the hospital, I could look into the male ER ward and then the female ward on my way to the stairs. About two-thirds of the beds occupied, the medical team huddled at a small wooden desk near the door, filling out forms on the flimsy paper stock everyone uses. ER staffing is one nurse for all twenty beds. A sort of extra haziness just in those wards; I remember how the air at Boston City Hospital used to get that same shimmery effect during a summer heat wave in the old Dowling Building. The deep smell of sweat, old saliva and other body fluids of all types along with carbolic. Never enough carbolic.

I kept walking and the housekeeper came to hand me the library key, clearly she was instructed to be on the lookout. Reminded myself to remove shoes before entering.

Students filtered in, this is not a punctual group. We did the quiz, and I looked over shoulders to check progress. I wrote “ramro” in Nepali on most. The original decision was to go quickly through atrial and junctional rhythms ( needed to identify PEA), then ventricular rhythms, do 12-leads, and talk about defibrillation. It was soon clear that this teaching plan was ambitious, and I needed to adjust. So I spent more time on rhythms then skipped 12-leads altogether. I introduced the “Six Onlyest Rhythms,” and that was the end of didactic for today.

Khana khanche, Bhairawa style

Today was blazing hot, and though the A/C was on at max, the power would cut out now and again. So – we were sweltering,which was a factor. One student who came from the hills, was having particular trouble and I poured water on her head, teasing her about baptism. The group took a long lunch (45 minutes) then came back to switch gears and roleplay some megacode scenarios.

For lunch nearly the whole class packed into one bhansa where a guy was rolling out fresh roti. They also had cold sour dahi which I love. (Locally made yoghurt) … It was vegetarian so no momo here, and it made me wonder what caste they served. BTW I was told that in this region of Nepal, water buffalo are used so much in agriculture, that they never eat buff, out of respect.

Side word about “bhansa” – it’s a sort of food place. “Bhansa” means kitchen but also utensils. I have sometimes referred to these as “roadhouses” – you might think of them as a “diner” I suppose, but the truth is, it’s as basic of a cooking setup as you can have. There is a bhansa located a hundred yards from my room at the Shalom Annexe. DBT usually costs about 100 nrs at these joints. It’s not the kind of place a videshi would take their sweetheart on Valentine’s Day. Maybe their wife though. 🙂

Role Play after Lunch

Clearly, mega code was the most valuable and appreciated part of the day, once again. Today we repeated the drills from yesterday and added new scenarios involving defibrillation. A review was needed, as the first groups failed to do a primary survey. We did a number of the scenarios, over and over and over with different groups.

For the last hour I reached into my bag of tricks and pulled out the brainstorm of the family dynamic scenario that I first used with the LNC BN students. We ended up doing it three times. The first two times became dramatic examples of “outta control.” To debrief I asked class members to step forward if they had personally experienced any scene similar to this, and four or five of the older ones shared their story. (I also gave them overt permission to tell their tale in Nepali). Many of the attendees are young, and I thought I could see that they were listening very carefully, knowing that they would be called upon to cope with similar situations.

Family-centered end-of-life ACLS?

The group wanted *more* of doing the scenario where they were being interrupted. Okay, we have touched a nerve here… Let’s think about it. For the third go-round, I asked the students as a whole, to show me what it would look like if it was a “success” – I.e., the team did the resuscitation and the family was able to grieve but kept out of the way. The group took awhile to plan, having an animated discussion in Nepali and carving out roles.

Here, one particular member of the class, probably the oldest, stepped up and played the role of a doctor in this situation. Due to her age I think she is an ANM, not a staff nurse – sort of an LPN I guess we would say.

So – an impromptu group project. The discussion, planning and execution were all conducted in Nepali. (Rama, one of my former TNS students, sat next to me and gave me updates as to what they were saying). Then they role played it.

The scenario featured:

A) patient’s family members, mostly female. One had a cellphone she would use to call a consultant from another hospital.
B) a confident chowkidar maintaining a clear boundary,
C) the nurses helping with resuscitation
D) A nurse as a go between
E) a doctor who was not afraid to be in control, and who also took time to teach the family.

So it was a sort of psychodrama I guess you would call it. For the younger nurses I think it will help process ways to deal with extraneous elements of resuscitation. Here, ACLS takes place in a specific cultural context involving the family and village members. It’s another take on the Truth about Butterflies. We can’t know the nuances of this butterfly without seeing the way it acts as part of a fluttering of butterflies.

Q: what is the “noun of assemblage” for butterflies, anyway? There doesn’t seem to be one……

One student got an i-Phone video of the last role play. I want a copy!

One of these days I will design a scenario which calls for the Universal Surgical Tool.

We debriefed by getting a list of things needed to make sure it always happens the good way, and my plan is to present this to UCMS administration as a recommendation in the post-training letter I will send.

Rickshaw part two

Monika accompanied me to the gate and helped me in my rickshaw quest, by explaining to the driver where I needed to go. This one was kinda thin, and said (in Nepali) “it’s hot and this foreigner is fat, I want forty rupees”.

No problem.

The first fifty meters of the way back are a slight uphill, only a gain or maybe four vertical feet, but on the other hand it was a hundred degrees…. and I found myself doing a bobsled move to help build momentum. The shuttle bus, on which many of the class members rode, honked from behind but we made them creep along. My driver laughed as he looked at them over his shoulder, then finally pulled over at one auspicious spot to discreetly take a leak. The bus zoomed by, all my students waving and laughing.

Further along, we had to take a sharp left, where about ten uniformed schoolboys lounged on a porch. They saw us and gleefully ran out to stop the rickshaw, an impromptu Bandh. A group project, you could say. Shouting and laughing, they said English words and held out their hands for money.

I laughed back, at the craziness of it all. Said the onlyest Hindi word I know; “Nay!” And pulled out my camera. This distracted them as they jostled to pose. Then they asked for a print, and I said “tell me email address” – when one started to point to his house the others told him he was dumb.

We finally got the rickshaw going again, after the driver was rested enough to scold them properly. The boys faded into the distance.

I gave the driver a hundred rupees when he deposited me at my door.
I rinsed out the scrub shirt I wear while lecturing, and hung it up. Spent time cooling off in my A/C room, and now that the sun is lower in the sky, I will go out to enjoy the pleasures of the town.

Joe Sar


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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One Response to Bhairawa side-trip day two – not on the weather channel

  1. On YouTube i posted a short interview with one of the nurses in the course, who specifically commented on the role play involvinbg family members and the stress of this. here is the link:

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