Where Do You Park an Elephant *During Monsoon?*

So I was up early to take taxi to Kanti Path near Thamel. It’s the point from which nice Tourist Buses depart for Chitwan and Pokhara.

Aarju Niraula met me there and we were joined by Rajani the in-charge of CCU. Turns out these two were classmates at Kathmandu University and they both have a B Sc.

On these bus rides you know you will have time to talk. Aarju is twenty four, just got married last year, to a doctor, whom I will meet later today. She’s been away from home 38 days.

There was a party of ten Americans from Sacramento California with us, headed to Chitwan. It was the first time I have been in the company of so many Americans in six weeks. I talked to one guy who said they’d trekked to Everest Base Camp and loved it.

There was a welcoming party when we stepped off the bus. Turns out the Matron of this place, who plays a dual role as Campus Chief of their B Sc program, is Sita Parajuli, at Mission Hospital for eighteen years then came here in 2006 – – so – she and I could gossip about everyone. She actually phoned Niranjan Sharma, just to tease him about look-who’s-here, which was funny – and then Niranjan and I passed pleasantries.

I got the tour from Hemant Gupta, the orthopedic surgeon. Hemant was a classmate of Bikash Gupta of Honolulu, and that’s the original connection through which I got this gig. (For awhile there I was trying to remember the chain of events that precisely landed me doing this activity in this place on this planet at this time but couldn’t…. That was scary. I am just *existing* at times, having dropped all extraneous ruminations as to how or why. It seems natural to be on the bus smiling as the two Hindu women chat away while we share butter crackers and look at the rice paddies in the valley below. Goats scatter as the bus slams to a creep. Doesn’t everyone do this?)

Lots of small Hindu shrines in this hospital. “Toto, I guess we’re not in Kansas anymore”

Hemant brought me to ortho ward first, it’s his shop. Since it was so darned hot everyone was on a siesta including the relatives chillin under each bed.

Then to pedi- they are hosting an “ENT camp” with ENT surgeons from India, so the right-hand half was chockfull, about thirty kids but each had two or even four relatives right there – it was full. “The Bus Station effect”. Left-hand half was not so full.

Sita joined us as we got to ICU. Here you remove shoes, but the slippers were too small so I padded around ICU in stocking feet. Fifteen patients in a big ward, green sheets, heart monitors, nurses drawing up meds. First a blur as you see the whole confusing scene and then the focus clicks into place and you look for one specific thing then another.

In ICU they have air-conditioning ( good since it’s 104 F today) piped-in oxygen, suction and piped-in COMPRESSED AIR!

O MY GOD! It’s the holy grail of Nepal Hospital infrastructure and it’s right here.

Short lesson in kitchen-table physics: compressed air is warm, and it takes energy to compress the air. Mechanical ventilators run on compressed air, and the pistons of these machines put out heat. If you have three or four of them running, they create quite a bit of heat in an ICU, even a large room, and can overwhelm the air conditioning 🙂

With piped-in compressed air, you bypass the compressor in the box itself – it’s not needed.

And – the air con will work!


Somebody here was/is clever.

I looked at the crash cart, e-drugs, defib, ventilator setup etc and thought the equipment was actually pretty well laid out.

They had an ample supply of sticky monitor-lead pads, a pet peeve of mine.

I told Sita I liked how they set it up, obviously some planning went into it. We discussed the ET and OP suction system.

ABG machine on-site, QC done by lab.

Leafed through the flowsheets. Watched the nurses. They were doing CPT on one guy.

The left hand side was the CCU side and it was quiet, just one guy with 3rd degree AV Block, and another lady with restrictive lung disease. The nurse on duty there was trained at Gangalal, got to Bharatpur via marriage.

This ICU has a fulltime chowkidar and manages to strictly enforce the visiting hours. About sixty relatives in the outer hallway.

It was hot. We met the CEO. It was cordial. We went to the classroom where I dropped off all my handouts etc for tomorrow.

To the canteen where we ate majhli dosa and talked. Himal, Sita’s husband, joined us. When Sita phoned Aarju to request that she come to class early, Himal chided Sita (“don’t you remember she’s been away thirty eight days?”)

Sita needs to upgrade the nursing lab (this is something I have heard from everyone) with better mannikins. We discussed the faculty shortage ( they are getting MSN-prepared faculty from India) and of course, the price of tea in China.

They will put me on the plane to KTM Tuesday. Somewhere along the way we will take a short side trip to a mandir on the riverbank, said to be a holy place to bathe. After all, this is a tributary of Ganges.

The class tomorrow will include her entire nursing faculty, and ten of the ward in-charge nurses. Not a lot of ingenues in the bunch. The plan is to train the leaders here and follow up by passing along new things to the other staff. BTW this is a 500-bed hospital with average daily census of 300, and they employ 300 nurses.

I will take a rickshaw to the Medical College in the morning. They said not to pay more than ten rupees

After class, I will meet with MBBS students of Parth (Aarju’s husband) as well.

They dropped me at the hotel. I could see the pool outside my window. A wedding was taking place – with – a brass band……….

Videos will be forthcoming.



Q: Where do you park an elephant *during monsoon?*

A: next to the tuba player. She is a musical elephants and she likes guys who have a deep voice.


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 Where Do You Park an Elephant *During Monsoon?*

  1. Atlanta limo says:

    ABG machine on-site, QC done by lab.

    • ABG is “Arterial Blood Gas” and QC is QUality Control.

      and ABG machine allows for state of the art finetuning of a mechanical ventilator.

      when ever you have a biomedical device, the next big hurdle is who will maintyain it and how it is calibrated; so when i saw the ABG machine, I asked this question. I believe the the hospital in Bharatpur has a well-run lab. it’s easy to get the equipment, considerably more difficult to keep it running properly.

      There is an NGO, by the way, which sends a person around to each and every medical lab in the country, to support the goal of accurate lab tests. I believe it’s part of Samaritan’s Purse but i can’t recall. The woman who does this is very dedicated and delightful, she is Swiss. she has been to every corner of Nepal in her job.

  2. Mark Schnell says:

    Elephants must be fond then of the beginning of Richard Strauss’s tone poem of a work by Nietzsche, This starts off with a double low C by the double basses, the contrabassoons, and an organ.

    You know the piece in question: Thus Spake Niemczurathustra.

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