May 31 about Advanced Life Support in Nepal

Please share this widely, among every nurse you know. I welcome your comments. Be sure to click on the hyperlinks, I spent time putting them in and some are meant to be fun.

Update – for the sessions to be held at Lalitpur Nursing Campus, the first session is full but the other three still have seats available. From Monday on, we will be registering on a continuous basis, at Lalitpur Nursing Campus. Go to the library there, bring a pen drive and 1,100 nrs. The fee covers fooding for the three days and registration. we will periodically update you as to how this is going.

In USA I am a former Instructor of Advanced Cardiac Life Support (ACLS) with the American Heart Association and also a former Regional Faculty for ACLS, which meant that I was qualified to teach Instructors.  Even before that, I was the manager (the “in-charge”) of an ICU/CCU for nine years, and I used to train nurses in critical care, since 1980 (before most of my students were born. my daughters are older than you).

Drill like a sports team

to train an ICU nurse always involves drilling on how to react in an emergency situation, and I used to spend hours running the drills with new staff in USA. Also, at University where I teach, we use many simulated situations to teach.

When I came to Nepal, I noticed that nobody did it that way, and I observed the way that nurses reacted during emergencies. Here were some really intelligent hardworking people who did not know how to respond when the patient was about to die. I set out to learn why. here is what I learned:

1) there is very little staffing in most hospital wards, just barely enough to get the tasks completed.

2) at PCL level, nurses are taught to focus on getting the tasks completed first and foremost. the paperwork assignments nowadays include about nursing diagnosis and assessment of the patient, but it is “medically focused” to understand the basic disease, not so much on the complications.

3) many hospitals do not own cardiac monitors or defibrillators, and in rural areas there are fewer heart patients than you would expect, because the patient must walk a long distance to the hospital (not a good idea if something is wrong with your heart).

4) at PCL level, nurses are not taught about “failure to rescue” or “rapid response” like in USA. in some places they are discouraged from using bag-valve-mask or CPR and do not know how to maintain an airway.

5) the faculty of many PCL schools do not know about these things, and can’t teach them or model them for the students. often the faculty are just a few years older than the students.

6) nurses are often afraid of telling the doctor that something is wrong with their patient, because they don’t want the (male) doctor to think his competence is being questioned. of course, an experienced person knows that even with the best medical care in the world, complications will occur and specific complications can be predicted.

7) when a new hospital is established, the first thing they do is to start a PCL level school of nursing, because students provide cheap labor and tuition is income for the hospital. The Nepali Nursing Council is working to make sure standards are being met, but there is dramatic growth and many teachers are new at their job. I believe we should be having more B Sc programs, not more PCL programs.

for these reasons, when I study the way the nurses work in Nepal, I developed techniques to use my background to teach how to overcome these obstacles. the core of what I teach is based on American Heart Association ACLS, though since I have fifteen years of University teaching experience in nursing in USA I draw on many things. please click here to learn about the term “failure to rescue” and you will learn about an important national trend in USA hospitals since 2003. Every nurse needs to learn these things, not just the ones who work in an official ICU. The nurses on Medical Ward need to know which patients belong in ICU. especially at night when there is no doctor around.

So is this an official ACLS class that you offer?

No, it is not. when I meet with doctors and leaders who know about ACLS, this is something we always seem to discuss. An official ACLS course with an official ACLS card, must meet a long list of specific standards related to equipment used, and materials taught. for example, in USA you must have an Automatic External Defibrillator (AED) and all students must learn about it. and so on. I looked into bringing an official course here this time, and it was way too expensive, plus it did not teach the things people here actually needed to know.

I  met a doctor who told me when the group from Delhi comes, they bring all the equipment with them, then bring it back to Delhi when they go. There is nobody in Kathmandu who can afford to buy all the manikins to keep here. The  course with the people from Delhi costs $250 USD per person. I met somebody else who said a group from USA came, then realized how different Nepal was. There were no manikins and no any simulators, so they said “we just can’t do what we were planning to do,” then left. They were highly qualified but they lacked imagination. I can teach CPR without an expensive manikin. I can teach dynamic rhythm response without a simulator ( though BTW, I brought two Pinnacle Tech A.T. 35s with me, the first in the country, and everyone agrees they are really fun and realistic).

You can have the knowledge without the official card

Many times, young doctors want the official course because it will help them get a medical internship in USA or Canada.  That’s okay and it will help the people of Nepal in a roundabout way, but let’s just train people for what they need to do in Nepal, who will stay here and use those skills here.

Advanced Cardiac Life Support is more than about heart rhythms, drugs, protocols and the defibrillator.

Most of all, it is about teamwork, and the official AHA ACLS manual is very clear about that point (pages 17 to 23 of 2010 Manual). you can have the smartest doctor in the world, devoted to duty and humanity, but if the nurse does not know how to identify deterioration and impending arrest, he will never be called. You can have the smartest doctor in the world, but if he is not supported by a team he will not be able to resuscitate the patient. and that is why the American Heart Association (“AHA”) places so much emphasis on “Effective Resuscitation Team Dynamics” in section 3 of their manual. it is unfortunate that people skip that section and read about the drugs.

Which language

The AHA book is written in English. Most Nepali health professionals are taught in English. When I come here I teach in English (mostly). But the class I teach is conducted in such a way as to help Nepali students whose English is not the best, to succeed, and often the discussions are in Nepali or when somebody asks a question in Nepali, one of the other students will answer in Nepali.


Important: you can still be a fine nurse even if your English is poor. If you are not so good at English, it does not mean that you lack intelligence. I suppose some videshis never learn this. You can be a very effective team member who does not speak any English at all. For that reason, I found somebody to translate that very section of the ACLS manual, the one on teamwork, into Nepali. I distributed it as widely as I could, including to every doctor on my email list, and I was surprised at the result.

“We don’t need to have anything translated. We all speak English,” was one reply, from a person who acted as though I was sending it to them for their use.

“Of course you speak English. But does every single person on your team have English as good as yours?” I was sending it so they could share with all members of their team. Nurses automatically share these things with those around them.  Many doctors I know also do the same. I hope this one will come to know how useful it can be.

If you want your own copy of the Section 3 that is in Nepali, to share with your team, send an email to

What we Teach

So, if you come to my trainings, this is what to expect:

1) we will teach you practical examples of how to be a team member. this includes knowing how to help the doctor and how to anticipate what the doctor needs when ACLS protocols are needed.

2) we will give you chances to practice in simulated situations where the patient is not “real” and therefore you don’t need to be fearful that you will accidentally harm them. You will gain confidence. this is not a sit-down-and-take-notes event. this is practical hands on, even though we do not go near a real live patient.

3) we will help you learn these things even if your English is not the best in the world. You can be very important to the success of the patient.

4) we will teach you how to identify certain early warning signs so that you can call the doctor before the patient’s heart actually stops.

we are still registering for the LNC classes, I invite you to join us!

After today, further registration will be conducted at the Library of Lalitpur Nursing Campus in Sanepa.


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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