The Light at the End of the 2011 Tunnel for Kathmandu Critical Care

Pani 6

It’s raining as I write this, cool and delightful weather. The fridge at the Guest House was repaired while I was gone, I cooked spaghetti and meat for myself last evening. I am sharing the Guest House with eight women from UK
who are soon embarking on three-month home stay volunteer experiences in the Terai. It’s pleasant but there’s only one bathroom. I’m a bit vague as to what their NGO does…..

Da Big Class rolls on like a juggernaut, crushing everything in it’s path.

Sometimes the best plan is to have no plan……. But that does not mean it’s easy to stand in front of a crowd knowing you have not planned a lecture. My big course, the large group in the ballroom with the crystal chandelier, meets weekly and it’s the one where I have tried to teach the most cardiology, in a systematic way. I have about a dozen nursing teachers in the course from various schools of nursing, and a cluster of nurses now working in this or that ICU; but then I also have a dozen or so B Sc grads yet-to-be-employed. Out of the seventy five who started I have lost about fifteen. Probably due to a) deciding they could not get over the language barrier or b) work scheduling.

One member of the class, a quiet person, told me at her hospital all the House Officers are now using the six-step guide (“the Fisherman’s Handout”) and that she is looking at strips every day now with the docs. Other anecdotal stories of small successes. So I’ve lost a few but I’ve won a few.

Megacode (def.) (Medicalese) 1) a simulation exercise in which a team of respondents composed of medical professionals displays their skills at using a treatment protocol during a cardiac or respiratory arrest. 2) a Cult-like masochistic exercise in self-flagellation in which nurses and doctors attempt to symbolically cheat death. 3) known in Oz as a “mock code”

Last week had been a bit frustrating for me, first because I still lectured even though I was sick, but also as I got feedback that told me I needed to make adjustments in the course. When the students are doing poorly it’s easy to attribute any problems to some flaw in the class roster. An experienced teacher has to consider adjusting the teaching style and methods. So the plan was to not introduce anything new, and to review course concepts. Prior to class I enlisted some of the course members to serve as co teachers for this session. In the morning we started with mega-code review for an hour as people straggled in, which was a change-up. In past weeks we didn’t do mega-code until after lunch. The early morning scheduling forced everyone to shift gears.

God can read an ecg and Also understands and speaks Nepali

At nine thirty, we then divided the entire class into three groups and did three fortyfive-minute sessions, rotating the groups through. At the first station, each student once again performed the initial survey of BLS. Next, a review of ecg, by two ICU nurses from Norvic Hospital. For this they used Nepali, and the whiteboard. ( It turns out that regardless of the patient’s language, the ecg is still the same. The true mysteries of the human heart are controlled by God, not man). At the third, I led the station that reviewed mega-code.

We had a good vibe at chiya, more students brought their cameras, and more huddled in small groups helping each other with small points of the class. Over lunch my new co-teachers sat with me and we discussed the plan for the afternoon, deciding to split into four groups and do four different variations of mega-code, thirty minutes each. A lot more doing and a lot less watching. Closer to the way it would be done in USA. Delegating students to lead some of the sessions was one more way for me to transfer ownership of the class to it’s members.

At each station we insisted that the students refer to the six-page protocol sheets, esp when the whole group is having a “brain cramp”. (yes folks, a resuscitation team is capable of temporarily forgetting what they are trying to accomplish). The closer scrutiny brought out such things as the idea that nobody in KTM ever uses vasopressin and it’s never been on the crash carts here, for example.

Low Tech version of dynamic rhythm simulator

At the megacodes we also did another new thing. Til now the person running the simulation simply stated the name of the rhythm for the students as it came up. Today, each station leader used a set of paper sheets upon which the various possible rhythms were drawn. The students had to glance up at the sheet and name the rhythm from there, for an extra element of realism, since it’s done on the fly in real life just like this.

Some groups responded to this by doing something hysterically funny which beginners do, which is, if a new rhythm is presented in this way, they all freeze while they gawk at it, as if they are deer looking into headlights (“don’t stop compressions! Keep bagging!”).


Anyway, at the end of the day there was some good mojo, an afterglow of successful engagement. a few of the students hung around to shoot the breeze. Next week we will revisit 12-lead ecg and do a short class on ABGs, but mostly focus on more megacode review, the actual team performance skills.

The week after that is the final exam. And a ceremony to present certificates.

My class for the 24th – 26th is filling up, I now have forty enrolled. For this I will use my new teaching colleagues for megacode; it will be a piece of cake.

My tentative class for the 17th, 18th and 19th with the MBBS students is cancelled, giving me some unexpected days off, which I will use to regroup.

Summer 2012?

I am starting to schedule meetings with various people in which the subject is how to build for future summers or future trips to Nepal. I am on Day Fifty Nine out of Seventy Eight.

Where did it go…..

Between now and then, I think I will take the time. A day here and there. To stop and smell the incense.



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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2 Responses to The Light at the End of the 2011 Tunnel for Kathmandu Critical Care

  1. Mark Schnell says:

    God’s ecg is printed out by a seismograph. When the Indo-Australian plate moves against the Eurasian plate, another Himalayum is born. Its birth pangs are measured on the Richter scale. The tremors of an earthquake are the contractions of mother India than give birth to daughter Nepal. A human’s birth is heralded by centimeters of dilation. That of a mountain is foretold by centimeters of continental drift per year.

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