May 28 report of CCNEPal part three


Please read parts one and two. In part one, I summarized the numbers of sessions, the locations and the people who took the 2-day (MBBS) or 3-day (for nurses and nursing students) versions of the ACLS course. In part two, I  gave a narrative of MBBS education in Nepal, with some things that stood out after teaching this population.

CCNEPal and the Earthquake

CCNEPal trained 2,130 Nepali nurses and doctors since 2011, and 800 of them from Kathmandu Valley. I got a FaceBook message May 5th:

I was in thamel when the 11:56 happened. A 5 storeyed building. Glad it didnt give up. I survived. Came outside to see 2 houses collapsed. We dug out 2 people, husband and wife with local resources live shovel. The emergency protocols came spontaneously to me. I was able to stabilize them both physically and psychologically. Then in the late afternoon, I went to Bir hospital NAMS to see if i could contribute as a medical student. I performed half a dozen CPRs and assisted in many other emergency management. Could not save them all though. Saddened me of course. Wanted you to know all this because it is all thanks to you and your teaching approach that everything came to me spontaneously. You did save a lot of lives from dharahara quake through me. Thank you.

Even if that was the only guy we trained, it was all worth it.

to respond effectively in a crisis requires the ability to recall complicated protocols and choose the ones to apply. We use in-class exercises to reinforce the memory, and previous groups have told that

to respond effectively in a crisis requires the ability to recall complicated protocols and choose the ones to apply. We use in-class exercises to reinforce the memory, and previous groups have told that “Joe, you are turning us into Jombies!” – but – you need to be able to decide how to execute – and that’s the serious purpose.

The landscape of Cardiac Life Support in Nepal and the future.

CCNEPal is not the only entity that is trying to bring Advanced Cardiac Life Support education to a wider audience. There are other groups filling specific roles to teach nurses and doctors, mostly Medical Officers ( a few years older than the interns).

The hospitals and medical schools in Kathmandu. Bir Hospital has taught a course like ours to the post-graduate doctors seeking their M.D. (Master’s) degree. Man Mohan Cardiac Center and Shahid Gangalal Cardiac Center have recently started teaching this course to  their Medical Officers, as has Patan Academy of Health Sciences and Grande Hospital. It should be noted, however, that in these locations the interns are not included, nor are the nurses. None of the instructor groups from these locations has ever travelled outside the Kathmandu Valley to the fourteen medical schools located in the rest of Nepal, and CCNEPal often hears “You’re the only one who teaches this who comes to Terai!”

Man Mohan Cardiac Center worked with CCNEPal to train the nursing staff in 2014, the same way that SGNHC did in 2013. We did a training for thrity five nurses hosted by TUTH nursing school; then MMCVTC sent nurses to each session we held at LNC. They have a highly motivated and talented crew, and it was an honor to work with them. CCNEPal has trained nurses from each of the cath labs in Kathmandu as well.

Man Mohan Cardiac Center worked with CCNEPal to train the nursing staff in 2014, the same way that SGNHC did in 2013. We did a training for thrity five nurses hosted by TUTH nursing school; then MMCVTC sent nurses to each session we held at LNC. They have a highly motivated and talented crew, and it was an honor to work with them. CCNEPal has trained nurses from each of the cath labs in Kathmandu as well.

The Center for Medical Simulation deserves special praise and mention. Nepal’s only Official International Training Center from the American Heart Association. There is a lot to say about this Center. I was proud to consult with them as to proper policies and procedures, and the courses they offer are on par with the high standards of the American Heart Association.  The BLS or ACLS card you get from The Center is the Official AHA card. Any doc who wants to take USMLE will find that taking ACLS from The Center for Medical Simulation is considerably less expensive than going to Delhi or the USA. Having said that, the fee for the BLS/ACLS is about 20,000 nrs per person. They offer group discounts.

The Center for Medical Simulation owns a complete set of BLS manikins and awards the exact same course completion card that you would get in the USA.

The Center for Medical Simulation owns a complete set of BLS manikins and awards the exact same course completion card that you would get in the USA.

Videshi groups. It is not unusual for one or the other Kathmandu Valley entities to bring in a group of videshi instructors from an American Medical School to teach the “official” ACLS or PALS course, or one of the other courses such as ATLS or PHTLS. For some reason, every outside group always announces that “We were the first that ever did it.” – Um, no. You can think that way if you like, but – last year’s group from USA was also enticed to come here with that same pitch. And the group the year before that…… near as I can tell, groups of foreigners have come here to teach Nepali docs for more than twenty years. In 2014 I listened politely as a pediatric cardiologist from the Mayo Clinic announced to me that she was involved in the first ever ACLS course at a major hospital. Was it the official course? no. Well then, I’d already beaten them to it by thirty sessions with nurses. No big deal. (and for the record, CCNEPal has taught 70 sessions as of May 2015.)

Special note about foreigners coming to Nepal to teach or train:  study this blog and the CCNEPal FaceBook page; and read my two books. You can not simply transport an American course here and think it will work.

Note; if you are a qualified ACLS or BLS or PALS Instructor or Regional Faculty from USA, contact the Center for Medical Simulation. Send them your affiliation paper work as soon as you book the flight to Kathmandu. You no longer need to bring the required equipment, or improvise. You can now teach in Nepal and use state-of-the-art equipment from The Center – much more efficient than hauling stuff back and forth. The Center also has state-of-the-art simulation tools. They have a “3G Sim-Man” suite as well, which they are just starting to use.

Train-the-trainer is a sexy word in these sort of teaching ventures. In my view, it allows the teacher to rationalize doing the logistics for a session that only reaches twenty people at the max. My estimate is that about 30,000 doctors and nurses in Nepal need this. Train-the-trainer is a drop in the bucket; and since the logistics of setting up a course are daunting, none of the train-the-trainer people seem to actually turn around and teach after having just taken it once themselves. There needs to be a culture of ACLS.  I’ll expand on this in a future blog.

Furthermore, focusing on training the “Top Guys”  never seems to result in sharing the knowledge with the Junior Guys (and ladies). The knowledge of ACLS, and the practice of resuscitation, needs to be widely known at the level of the person who is working in a Casualty Room on an offshift, and not limited to the Senior Consultant from the Anesthesia Department.

Training Nurses Part One Any hospital or school that does not also train the nurses, simply does not have an effective ability to do resuscitation. And any person who disagrees with me is proving their ignorance.  I won’t be polite about this point.

Nurses need to learn how to do this. (don't try this at home. these are trained professionals under expert supervision)

Nurses need to learn how to do this. (don’t try this at home. these are trained professionals under expert supervision)

Training Nurses Part Two if your  hospital has an ICU or ER, every nurse in that area needs to have this training. If they do not, and especially if you do not value it, you don’t have a real ICU. The ability to do critical care is defined by training and teamwork, not by an inventory of equipment. Simple.

In May of 2013, CCNEPal started routinely including an anatomy lab in the 3-day session for nurses, to make up for gaps in science preparation ( something I had done in USA for years). For this we obtain en bloc heart-lug assemblies of mutton from local fresh shops. Here's a shot of the coronary arteries.

In May of 2013, CCNEPal started routinely including an anatomy lab in the 3-day session for nurses, to make up for gaps in science preparation ( something I had done in USA for years). For this we obtain en bloc heart-lug assemblies of mutton from local fresh shops. Here’s a shot of the coronary arteries.

Training Nurses Part Three I think CCNEPal should consider awarding a prize, or a Token of Love, or something, to any ICU that achieves 100% training of their nursing staff. Either certify the nurses with the AHA ACLS course or with something equivalent to the course CCNEPal teaches.

The American ACLS Course has it’s place but does not fit the needs of Nepal.

– The AHA has detailed requirements for “mandatory equipment” for each course. It leads to formidable start-up cost that makes it too expensive. With a bit of imagination,  you can do a course with improvised equipment that is not such a large investment.

This is the stuff  CCNEPal uses to teach the course. Another view of all the stuff, laid out so I won't forget something. note the

This is the stuff CCNEPal uses to teach the course. Another view of all the stuff, laid out so I won’t forget something. note the “CPR manikins” deflated in upper left corner🙂

– The protocols need to be adapted to reflect the clinical practices here, and what Nepal can afford.

– And most of all, the “English only for all discussions” requirement of AHA is not helpful. Click here for some examples of ACLS core case scenarios conducted in Nepal Bhasa. Let’s teach the stuff in the language it will be applied. A nurse or doc can be expert at this even if they speak no English. Because of the way the CCNEPal course is structured, every participant is able to get all their questions answered in the language with which they feel the most comfortable. Yes, most nurses and docs speak English. But – don’t underestimate the potency of this tool.

There needs to be a Nepali ACLS certification system. Sure, you can use the latest research-based findings of ILCOR, but the wallet card needs to have little Nepali flags on it, and scratch out the word  “American.” Click here to read about specific ways I adapt the course to fit Nepal.

Train Intern-level MBBS docs. In my view, the most important curriculum change that needs to take place in medical education is to require all interns to take an ACLS course before they complete their internship.  In USA, medical students take ACLS before they graduate. Nepal needs this.

MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal's future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal’s future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

Establish a national network to teach this. There are twenty medical schools in Nepal, and each should be teaching this. Every B Sc program in nursing needs to teach this.

About Joe Niemczura, RN, MS

Experienced nursing educator and problem-solver. I have fifteen years of USA nursing faculty background. Add it with 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. I travel outside of Kathmandu Valley as well. When the recent violence happened, I knew the cities - I had trained people in those locations. 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. Global Health Nursing is not all sweetness and light; not solely milk & honey and happy moms and babies.
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3 Responses to May 28 report of CCNEPal part three

  1. Brian says:

    There is great responsibility in being the “first.” Namely, ensuring you’re not second. #1 is a bold claim that requires curiosity, thorough investigation, and sound counting skills.

  2. Pingback: What every nurse and doctor in Nepal needs to know about Triage of mass casualties Sept 7, 2015 | CCNEPal 2015

  3. Pingback: CCNEPal planning for summer 2016 | CCNEPal 2015

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