CCNEPal report as of Oct 2nd, 2014

Summary: every public thing stops in Nepal during Dasain. I decided not to go trekking, so I am just hanging out in Kathmandu. It’s a good time to reflect on progress.

to begin with, here is a list of the sessions I have conducted since arriving in late May:

Session dates and locations Contact person
June 8, 9 and 10, CMC Bharatpur Mrs Laxmi Rajbandari, Matron
June 11,12,12 CMC Bharatpur Mrs Laxmi Rajbandari, Matron
June 18, 19 20; 22,23, 24 KU Dhulikhel Rajendra Khoju, MD and Mrs. Regina Singh.
June 26, 27, Tamakoshi Sewa Hospital, Manthali Suman Karmacharya, MD medical director
July 7,8; 9,10; CMC MBBS Bharatpur Rano Mal Piryani, MD, CMC medical school
July 13, 14 CMS MBBS Bharatpur Manohar Pradhan, MD Director of Casualty.
July 16, 18 ,18 CNE Planet, Biratnagar (double sessions) Dipty Subba and Raj Mehta (now at CMC)
July 31, Aug 1, CMS MBBS Bharatpur Manohar Pradhan, MD, Director of Casualty.
Aug 3,4,5; 10,11,12; 17,18, 19; 24,25,26. Four sessions at Lalitpur Nursing Campus, Sanepa Mrs. Radha Bangdel, Campus Chief
Aug 6,7,; 13,14, 15 doctors and nurses at Sayeed Memorial Hospital in Kalanki Dr Ankit Rai, Medical Director
Sept 3,4,5; 7,8,9; 19,11,12th; 14,15, 16;   CMS in Bharatpur. Nurses, BN and B Sc students, and MBBS. Mrs. Sita Parajuli, matron of CMS
Sept 19,20,21; TUTH Man Mohan CVTVTC Mrs. Bimila Cansakaar, matron
Sept 25,26; LMC, Palpa Raju Shakya, MD Deputy Hospital Director


The total number of certificates given to participants is 608 as of today. I missed a couple groups somehow, but on the FB page is a group shot of each batch, and when I view them as a slide show it’s amazing to me how many. I am not able to remember all the names. I adopted an approach of delegating the role of “assistant” within each session, in an effort to develop more leadership skill in this method of teaching, and I now tend to interface with the four or five such persons in the class, more personally.

This exceeds the number awarded in 2013 (534).  I have conducted about 23 sessions of the course, half of them outside the Kathmandu Valley. I continued my past practice of four first-come first-served courses using Lalitpur Nursing Campus space, but the rest of the courses were all sponsored by one clinical agency or another.  I was not able to fulfill all requests for collaboration, there are about ten hospitals/schools that are on  a waiting list.

2-day version

I added a 2-day version of the course, for MBBS docs, to go along with the 3-day version for nurses. Far and away, the largest number of participants for the MBBS version were in Bharatpur, both CMC and CMS. The classroom dynamics and course focus makes a shift when this is the audience. My experience with this group has given me valuable insight into the learning needs of young docs in Nepal. I plan to work with this group more.

Prudent Meditech, and the Center for Medical Simulation (CMS)

I have interfaced with Mr Rajesh Agrawal since 2011 when I investigated the idea of buying a CPR manikin, and when I got in touch with him this year, there was exciting news. He is a business man in the medical supply field, here since 1993. He has been taking many affirmative steps needed to develop a Simulation Center here in Kathmandu, to the point of renovating a suite of offices into classroom space, ordering a state-of-the-art “3G SimMan” and launching the steps to have an official “International Training Center (ITC)” fully certified by the American Heart Association (AHA), for the purpose of teaching ACLS and BLS and PALS according to every standard of the AHA.  I was delighted to hear this, because this center will be something that promotes my exact goal: advancing the standard of ACLS in Nepal.

And so when in town I have voluntarily consulted with him on the steps. The ITC coordinator will be Srijana Kansakar, who has a BSN from Alabama, USA, and a team of nurses.  I reviewed with them the Program Administration Manual (PAM) and drafted some Policies and Procedures. I am still independent of the Center for Medical Simulation but we have discussed ways I can help. To begin with, I think the application process laid out in the PAM is baffling to any person not steeped in USA health care middle management. The idea of this kind of NGO certification is very new in Nepal. For CCNEPal I had looked into doing something like this a year ago, and concluded that I could not bankroll it or afford to buy the mandatory equipment to run an “official” ACLS course. CMS is well capitalized and able to afford to do it right.

Instructor Bottleneck

We identified the biggest problem CMS will have, which is to develop a cadre of BLS-I and ACLS-I instructors and meet the required ratio of instructors for each class. So far, there are very few ACLS-Is in town, and they are all doctors who have active practices. In order to get the certification they have needed to got Delhi, since there is no place to get certified as an ACLS-I in Nepal.  CMS is fortunate that the medical leaders of hospitals have the vision to support this, but also faces a dilemma: how can they offer enough courses when they are competing for the time of some of the most talented doctors in Kathmandu?

National Policy on critical care and ACLS

as an aside, the Ministry of Health, and also the Cardiology Society of Nepal, have begun to put ACLS on their agenda. I like to think that my efforts have helped bring this pressing need to the attention of policymakers sooner than might have otherwise been the case.

back to the Instructor bottleneck, and the “Monarchy of Gambia.”

At this time, CMS has proposed a plan to AHA about how to expand the instructor pool.  I briefly explored the idea of reactivating my Regional Faculty status within AHA (lapsed since 2000), to do this, but it would have taken time, cost money, and distracted me from my core teaching of critical care using the format I now have. I come back to the same conclusion I reached a year ago: I am having better impact by doing what I do without the need for a set of “certification cards” to make me feel official.

I call this the “King of Gambia” theorem. The knowledge that I have is free, and up-to-date. I am a master of classroom management techniques that meld South Asian learning styles to the content. I have had excellent feedback about the course. Would this be enhanced if I were to announce that I was now crowned the King of Gambia? or some such other foreign title? At this point in my life, I can offer what I need to offer without needing another line on my resume.  Flirting with the idea of becoming Regional Faculty of AHA for Nepal is equivalent to being High Potentate of Gambia. I’m too old to be motivated by this anymore.

Having a “Crew”

Having said all that, I am helping them as much as I can, right now, without waiting for any particular certification as a go-ahead. I have shared with them my ACLS-I materials. This is a package of stuff I bought for $200 USD last year. CMS has four nurses now on the payroll who will be the backbone of the cadre in administering the courses, and I am orienting them to the AHA culture, values and standards.

Migrating my course toward an AHA format, sort of

The core of our collaboration is that they are  now my semi-permanent “assistants” for each session, since early August. An AHA ACLS course is set up with short periods of video, then discussion by the Course Leader, then work in small groups. Each small group does a role play scenario, and then gets debriefing. Up to now, I improvise this when I go form place to place, using assistants I recruit one day one of each session. From here on while in Kathmandu, I have the same crew of Assistants each time. We are refining the skills, and giving them practical experience that allows them to develop. I have revisited the ACLS-I materials including the layout of their official ACLS-I class, and I am using that to as a resource to develop their skills consistent to what the AHA expects. In the next month or two, I will be adapting my course format to incorporate more of the ACLS debriefing tools, so they will each become more able to use the AHA format. I’m happy to have the help of Srijana, Manika, Lochan and Binda for these courses, and these activities are ones I can do right now, without waiting for benediction from somebody halfway across the world.

We hope to add to the pool of Instructor candidates. If there are any people out there, especially MBBS and MDs, who want to help do this teaching, please contact me.

Future direction

I am needing to reapply for my visa. Every office in Kathmandu is closed during Dasain. If this is not approved, I will be taking a two month break and returning to Nepal January 2nd. I expect it to be approved. When that happens I will be travelling more to western Nepal, especially to Lumbini Medical College where I have been appointed as a volunteer Visiting Faculty.

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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