Ten Rules to Prevent Thrashing of Doctors in Nepal

Update October 2nd 2016
In Charikot, Dolkha district, there was an “incident.”  I do not pretend to know the details, but one pertinent feature was publishing a videotape of the doctors involved, apologizing for what happened.  Fortunately, these particular doctors did not get “thrashed” –  but the video had the effect of making the incident very public and underlining the threat faced by young doctors in Nepal as they work with limited resources in rural areas.
Original story  (written long before the “Charikot Incident”)
When a patient dies, the doctor is often blamed, and the family is angry. Thrashing the doctor is is a problem throughout Nepal. I made this list for my most recent sessions of Critical Care Class. The reality is, we are all going to die, and when we do, there is nobody to “blame.” It is not the doctors fault.
Communication is the key
Effective resuscitation more than just the ecg, BLS and drug protocols. The leader of the team must manage the interactions with patient party, and also with administration and police if things do not go well.
The Leader of the resuscitation team must recognize that the team is not just the other doctors and nurses, but also the guards and sometimes the police. It is not enough to only focus on resuscitation. Also, in previous blogs I have given link to checklist for secure building.
1) Goals The goals of resuscitation are always:

a) conduct the most effective resuscitation effort possible,

b) allow family to express emotion, ‎and

c) keep all parties safe from harm.

2) Weapons if any patient party shows a weapon, run away. You are never being asked to sacrifice your own life for doing this work.
3) Access limit access to emergency room or ICU asap when critical ‎situation develops. All exits and entrances must be guarded or secured.
4) Security Guards communicate with chowkid‎ars. This is two-way. Chowkidars serve as eyes and ears beyo‎nd the ER door. If patient party outside is upset, they alert staff. If staff is having problem, guards are notified. If problem develops, chowkidar sends for extra help. If ER doctor directs doors to be shut, immediate limitation of traffic must take place.
5) Police pre-enter phone numbers of administrators and prahari into all smart phones. If a situation gets out of hand you do not want to be looking up the number. For that matter, invite the local police to the ER on a quiet day so you will know each other.
6‎) Counseling send staff person to sit with anxious relatives. Staff person assesses education level and directs teaching to most educated person present. 
7) Chairs give patient party opportunity to sit. (‎more difficult to get physical).

8) period of respect after death if death occurs, ALWAYS wait fifteen minutes before allowing family to view the body so that remains will no longer be “twitching” – this is very upsetting and confusing to many persons.

9) mutual support doctor brings a nurse and chowkidars when counseling patient party.

10) Tone of voice pay strict attention to tone of voice of staff at all times. Apply principles of “de-escalation” whenever tone starts to escalate.

This blog has given ample advice on this subject, browse past entries to learn more.


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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