Bharatpur/Chitwan is the “Medical City” of Terai part one Oct 11th 2016



from the CMC website, architects drawing. Like most of the big hospitals, CMC is perpetually under construction. But they are well on their way!

Bharatpur, Nepal is located where the east-west highway  intersects with the highway to Kathmandu and Pokhara. Tourists going to Chitwan National Park to see wildlife go through Bharatpur on the bus. Because of the location, Bharatpur is home to four major hospitals.

College of Medical Sciences Teaching Hospital; (also known as “Purano Medical College”)

Chitwan Medical College Teaching Hospital;

the Bharatpur District Hospital, and

the B.P. Koirala Memorial Cancer Hospital

Each of these has their own sprawling complex. There are many smaller ones such as Pushpanjali Community Hospital.

There are fourteen nursing schools in greater Bharatpur.

I’m doing a series of entries on the places I teach when I am in Nepal. I’ve already described Janakpur and Biratnagar as well the National Burn Center in Kirtipur. I would be remiss if I didn’t describe the ones in this city. The challenge is, I spent a lot of time here and I know many people – it’s hard to do justice!

In general, institutions in Bharatpur do not have the kind of hosting arrangements enjoyed by some of the places in Kathmandu enjoy. They all express the interest in developing contacts. If you are from USA and you are looking for a potential partner to collaborate with, Bharatpur is a prime site for such things. Let me know.


This was new in 2016. it’s about one km from CMC.

You can get organic coffee in Bharatpur these days. When I was there in 2016, I learned that CMC is leasing space for a Lavazza coffee café just inside,off the main entrance.


site of future Lavazza coffee shop at CMC lobby floor CMC has also contracted out with a bank to put a branch on the premises, to handle all patient accounts.

Focus on Chitwan Medical College (CMC)


the front entrance of CMC. Because CMC is at the top of the hill east of the downtown, it presents an imposing view from far away. this is close and doesn’t do it justice…

the main feature of the ground floor is an interior plaza


looking down onto the plaza from fourth floor. Judging by the uniform, these are MBBS students. It’s a grand spot for morning conference

CMC has four ICUs.


One of the ICUs at CMC. Dust is pervasive in this climate. To enter this ICU requires going through a sort of airlock that keeps the dust down

another ICU. they’ve recently reconfigured their ICUs and relocated.


surgical ICU at CMC

Nisha Bhandari is one of the senior nurses. She helped CCNEPal when we did four sessions in a row to train 120 MBBS sessions, and now she also does inservice training for other activities.


CMC’s 2016 faculty development workshop. Dr. Rano M. Piryani, is third from left in front row, he has been strong advocate for critical care skills collaboration. Mr. Siddeshwor Angadi of the nursing faculty s seated o the right end in front row, he’s my main colleague for day to day teaching.

CMC does an annual faculty development workshop for all disciplines.

Health Professional Education and Research Center.

HPERC is a new initiative of CMC. In the Nepali MBBS education system, , each batch of interns leaves for a year or two working as a Medical Officer. There is incentive for them to accept assignment in a rural or under-served area. HPERC is designed to provide Continuing Medical Education to this group, so they will more easily advance to post-graduate (PG) level and ultimately, training as a specialist with the title of “MD”

Ultimately all Medical Colleges are destined to develop a similar setup.


generally the mechanical ventilators are from European maufacturers. Like other major hospitals, CMC has four or five different models.


Nurses desk at Emergency Room


this also is well-lit and busy.

a few pictures of emergency equipment setup.


med drawer. throughout Nepal this is the standard setup. somewhere along the way everybody decided to do it this way. note that each ampule sits on cotton wadding to mitigate breakage

and another:


this is what you see when you pull out the drawer.

One of the defibrillators


CMC owns more than one defibrillator, and this time around we used the above for training. It’s not my favorite. The nice one ( Nihon-Kohden) was in use in their cath lab.

tour of fundamentals lab at CMC

tour of midwifery lab part one.  Siddeshwor took me on a tour of the nursing education facilities, in a different part of town from the Teaching Hospital. I’m always interested to see what kind of learning lab they have.

tour of midwifery part two


On YouTube I posted a series of interviews with nursing leaders, and here is one with the Matron of CMC. In Nepali.

There are not many psyche nurses in Nepal, and Mr. Ramesh Subba is a resource.

I’ve previously described the AT-35 rhythm generator. The video below shows what it does, I took this at CMC back along.  (2013)

I have more pictures of the training and the people, but I think this is enough for now. I do not conduct sessions at the District Hospital, but I have pictures of it and many of their nurses have previously taken my training when they were students at CMC or CMS.

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what you need to know about Scrub Typhus in Chitwan, Nepal Oct 11th 2016 caught my eye yesterday:

RATNANAGAR, Oct 10: As many as 59 new cases of scrub typhus infection have been reported in Chitwan district in Asoj, pushing the number of patients in the district to 264 in the last six months.

According to the Insect Controller Inspector at the District Public Health, Chitwan, Ram Kumar KC, this bacterial disease has already claimed two lives in the district so far.

A total of eight persons have been reported dead due to the infection since its outbreak in the eastern part of the country, shared Resham Lamicchane, Public Health Officer at the Epidemiology and Disease Control Division under the Ministry of Health.

According to him, scrub typhus cases have been reported from 37 districts. RSS from Republika

Is That It?!?!?!

Yes. Normally I only excerpt a longer article – but that’s the whole enchilada right there.

Okay, it’s Dasain, and nobody is reading the papers and nobody is really writing any actual journalism it seems.  (this blog gets noticeably fewer hits as well). Here is my  problem. The article tells us there is an outbreak  – that is good. But it tells nothing about what the symptoms are, how to prevent exposure, whether the treatment works, etc.  They  reported it, yes; but they could have also done a public service.

Fortunately we have the internet.

Here, as a public service, is some info about scrub typhus. Now, I am a person who reads about deadly infectious diseases just “for fun” and enjoyment. ( I think I need to get out more). Next, the other name for scrub typhus is – Tsutsugamushi disease. I laughed out loud, because I always loved that word. An MD friend of mine once did a locum tenans job in Brownsville Texas and told me it was endemic there – about the only place in the USA he said.


from this lesion is very closely associated with scrub typhus. When you find it, go to the hospital for antibiotics. It may be under the clothes in an uninspected area.

Preventive measures?

Preventive measures in endemic areas include the following:

For those who do not know the location, it is Ratnanagar – just east of Bharatpur/Narayangarh. You go through Ratnanagar to get to Chitwan National Park.


(my photo) Rush hour in Sauraha, next to Chitwan National Park. This is what the tourists see. Most cities do not actually have these.

People go through Ratnanagar but (the tourists anyway) do not stop.  In Chitwan national Park one popular activity for tourists is to take a nature hike. Use insect repellant if you do.


Interestingly, it is treatable with antibiotics. One option is Chloroamphenicol, an antibiotic no longer in use in USA. There is no vaccine.

An excellent monograph from USA’s NIH this gives a technical analysis of the “laboratory bench” diagnostic tools. In the meantime, if you have a patient with febrile illness, look for the eschar; and consider the possibility of scrub typhus. In Nepal, it seems more likely in Terai, but at this time of year, people travel for Dasain, the big homecoming holiday.

something every nurse and doctor who reads this, can do.

use your smartphone to show the picture of the eschar to all your  colleagues, esp if you work in a clinic or emergency room.

If your patient has recently travelled to Terai and returned to Kathmandu, be on the lookout!

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CCNEPal goes to Norvic Hospital, Kathmandu August 2016 – some pics


the cafeteria at Norvic was restaurant quality, with a waitstaff. The canopy was covered by a blue tarp, giving it a distinctive look.

In August 2016 CCNEPal conducted a session of the three-day course at Norvic Hospital in Thapathali, a neighborhood of Kathmandu right near the river. This was not the original plan, but turned out to be fortuitous and fun.

Web page

go to and take a look. Norvic comes with an impressive list of “firsts” – first private hospital, home of the first cardiologist in Nepal, first cath lab in Nepal, etc. The School of Nursing at Norvic has a FaceBook page


this is not directly clinical “first” compared to angioplasty, etc. But – medical waste is a looming challenge in Nepal and Norvic seems to have designed a system for handling it. bravo!

Norvic is probably the best hospital in the country. I know I know I know, quality is elusive and arbitrary.  Also I know hundreds of nurses and doctors and I should be careful not to offend anybody since there are many wonderful people who work elsewhere. Also, on each of the two occasions when I was sick or injured enough to go to the hospital, it turns out that Norvic was not where I actually went, after all. But I liked a lot of things they did, and if I were sick and had a choice, Norvic is where I would go.


In Kathmandu mid-morning chiya and biscuits are just the thing. Before the CCNEPal project is through, we will consume one million cups of chiya and two million biscuits. and I always ask the participants to toast – they toast the previous groups and the future groups. ( note: a few people got nescafe – OMG!)

I’ve not previously conducted training with them on their turf, though in the past (2013) they cycled their entire cath lab staff through my series of trainings at Lalitpur Nursing Campus. Most of the cath lab staff were new since then but several had previously taken my course.


In Norvic cath lab. lead aprons neatly stowed. ship shape!

My contact person was Mahima Khoju, RN, BSN. Mrs. Khoju got her nursing degree from the University of Texas at Arlington, back along. I think we emailed back and forth for six years before we finally met in person.


Mrs. Mahima Khoju, my contact person. If her friends from UTA could see her now…. actually, the head gear is not her usual, it’s the same puggri every body else tries on sooner or later, my favorite prop for the course.

Cath Lab at Norvic  – I got the tour, but the video was cut short when the battery died.

patient care areas


one of the Medical Wards at Norvic. light and airy and dust free.

Above is the layout of the medical-surgical wards. two nurses are standing with the dressing cart. it was time for morning care, and all the drapes were pulled.


a small Newari temple in a courtyard on the premises of Norvic.

Heart Command Center

The tour focused on the ICUs in the hospital. For the Heart Command Center, one  of the staff nurses gave me a specific commentary on the equipment. This is probably boring to anybody who is not an ICU nurse, but if you are? it’s dedicated to YOU!

the above gives you an idea of the equipment they have. I was interested in the external pacer box. Pacing is a thing with me. Nepal needs a more coordinated national system of how to get it for people who need it. we take it for granted in USA, but for many outlying regions if you need it you won’t get it unless you can make it to a place that has it…..

here is a poster that they still display to celebrate World Heart Day from a few years back:


sort of a re-union of heart patients.



In the ACLS protocol, “MONA” is a mnemonic device to recall certain drugs we use. I have a long-running joke about MONA, and MONA appears in my handouts. CCNEPal has trained 2,885 nurses and doctors, and only two were actually *named* Mona. So – we had a running joke for several days. Childish? mebbe. Fun? definitely!

Tokens of love


the group picture. the 23rd of 24 groups for summer 2016. probably one of the top five groups in the history of CCNEPal ( the others being MMCVTC, SHNHC, the 2011 LNC BN group, and one other whom I shall not name).

Just me and the guys


“The guys” wanted a picture.  Men do not attend nursing school per se,  but there is a parallel PCL course named “Health assistant”  that enrolls males.  I loved their attitude and sense of humor.


Haku Patasi

The final day was wrapped up with a ceremony, as always. My hosts asked me ahead of time if I had any preference for a “token of love” – and I told them. So I was delighted to be presented with two “haku patasi” and a hand-carved tea box with Ilam tea in it.


made of Nepal-grown homespun cotton, the traditional sari of Newari women. These were for my daughters. Not the usual souvenir of Nepal.



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चरीकोटमा भएको जस्तो हमलालाई कसरी टार्न सकिन्छ ?

ग्रामिण क्षेत्रमा स्वास्थ्य सेवा उपलब्ध गराउँने चिकित्सकहरू को हुन् ?

नेपालमा एमबीबीएस डिग्री एउटा स्नातक तहको चारवर्षे कार्यक्रम हो जसको अन्त्यमा एक वर्षे इन्टर्नशिप गर्नुपर्ने हुन्छ। चारवर्षे यो कोर्श अत्यन्त प्राज्ञिक खालको छ र यसमा पढ्ने र परीक्षा लिने विधिमा जोड दिइएको हुन्छ। एक वर्षे इन्टर्नशिपको बेलामा मात्र युवा चिकित्सकले विरामीहरूको परिक्षण गर्ने, चिरफार गरेको हेर्ने वा त्यसमा सघाउँने अनि आदेशहरू लेख्ने गर्छन्। इन्टर्नशिप पछि ति चिकित्सकले एक मेडिकल अफिसरको रूपमा पेशा आरम्भ गर्छन् र त्यसपछि मात्र तिनिहरू स्नातकोत्तर अर्थात पोष्ट ग्र्याजुएट (पिजी) तालिम लिन जान्छन् जुन मास्टर्स डिग्री समान हो । यसले उनिहरूको नामको पछाडि एमडी उपाधि प्रदान गर्दछ। एकजना एमडीलाई वरिष्ठ चिकित्सक मानिन्छ।

‘’चरीकोट काण्ड’’

हालसालै दोलखा जिल्लाको चरीकोट स्थित अस्पतालमा भर्ना गरिएको एक बालकको मृत्यु भएको थियो। एउटा रिपोर्टले उक्त घटनालाई बिस्कुट खाँदा स्वास नली बन्द भएको भनेको थियो तर त्यसको छानविन हुँदैछ। प्रतिकृया जति यसका विवरणहरूको महत्व छैन। मृतकका परिवारले तीनसय मानिसहरूको भिड जम्मा गरे र चिकित्सकहरूलाई धम्काए। जव स्थानीय प्रशासनले भिडलाई तितरबितर पार्न सकेनन् तव उनिहरूले चिकित्सकलाई मानिसहरूको भिड अगाडि उभिएर क्षमायाचना गर्न बाध्य पारे। उक्त दृष्यको भिडियो खिचेर यु ट्युवमा प्रकाशित गरियो जुन निकै छिटो फैलियो वा भाइरल भयो जसलाई पाँच हजार भन्दाबढी मानिसहरूले हेरेका थिए।


I gave out brochures for the classes offered by my friends at the Center for Medical Simulation in Kathmandu, Nepal’s only “Official” International Training Center for ACLS with the American Heart Association

नेपालमा अल कायदा

मेडक्रोम साइटमा प्रकाशित एक समाचारमा चरीकोट भिडियोलाई अल कायदाले शरीर बन्धक बनाउँदा जस्तै तरिका उपयोग गरेको भनेर तुलना गरिएको छ। नमस्कार गरे झैँ गरेर ६ जना युवा चिकित्सकहरूलाई उभ्याइएको हेर्दा पिडा अनुभव भएको थियो। मलाई लाग्छ हरेक चिकित्सा शास्त्रको विद्यार्थीले आफूलाई अपमानित गरिएको अनुभव गरेका थिए र त्यसको मार सबैमा परेको थियो। स्वास्थ्य मन्त्रालयले उक्त घटनाको छानविन गरेर तीन दिन भित्र प्रतिवेदन दिन तीन सदस्यीय टोली पठाएको थियो।

सबैले के कुरा थाहपाउन आवश्यक छ भने यो यदाकदा मात्र हुने गरेको पृथक घटना थिएन र यसलाई त्यसरी लिइनु हुन्न। म एकजना विदेशी भएपनि म सित नेपाली नर्सिङ्को लाइसन छ र म नेपालमा हुँदा सम्वेदनशिल हेरबिचार सेवा पढाउँछु। मैले नेपालको धेरै ठाउँहरूको यात्रा गरेको छु। हजारौँ नर्स र चिकित्सकहरूले म सित कक्षा लिएका छन्। मैले नेपालमा कृतिम स्वास प्रश्वास गराउँने प्रभावकारी उपाय र अवरोधहरू माथि अध्ययन गरेको छु। यो कोर्शमा सफल परिणाम हासिल गर्नमा अवरोध गराउँने कुराहरूलाई निर्मूल पार्ने वा त्यसको सामना गर्ने तरिका सिकाउँन तयार गरिएको हो। सन् २०११ देखि नै मैले विरामीहरूका आफन्तहरूले देखाउँने गरेका आक्रामक व्यवहारलाई सम्बोधन गर्न स्वास्थ्यकर्मीहरूलाई सघाउँने तालिमलाई समावेश गरेको छु। यसमा भूमिका निर्वाह गर्ने तरिकाको उपयोग र त्यसपछि उक्त विषयमा जानकारी दिने कुरा समावेश हुनेगर्छ। म प्राय गरेर नर्स र चिकित्सकहरूसित उनिहरूले कामको सिलसिलामा यस्ता खालका भिडको प्रतिकृयाको अनुभव गरेका छन् वा छैनन् भन्नेकुरा सोध्ने गर्छु। हरेक अनुभवी चिकित्सक वा नर्सले यस्तो अनुभव गरेका हुन्छन्। त्यहाँ सयौँ कथाहरू छन् जसले तपाईँलाई स्तब्ध बनाउँन सक्छ। यो दोलखामा मात्र भएको भनेर नसोच्नुहोस काठमाण्डुमा पनि घटनाहरू हुन्छन्। उदाहरणको लागि गत बसन्त ऋतुमा पाटन अस्पतालमा ड्युटीमा नरहेका एकजना प्रहरी अफिसरले दुईजना चिकित्सकहरूमाथि मुक्का प्रहार गरेका थिए।


चरीकोट घटना चर्चामा आएपनि त्यस्ता धेरै घटनाहरू सार्वजनिक चर्चामा आउँदैनन्। यो भिडियोका कारण सो घटनालाई वेवस्ता गर्न गाह्रो हुन्छ, र यसमा सबै चिकित्सकहरूको नाम प्रकाशमा ल्याइएको छ। यो पनि अचम्म लाग्दो कुरा छ कि स्थानीय प्रहरी यसमा असफल भएको छ। यि सबै घटनाहरू न्यायिक प्रणालीमा जानु आवश्यक हुन्छ। तपाईँले यसमा चिकित्सकहरू दोषी रहेको ठान्न पाउँनुहुन्न। उक्त अस्पतालका लागि सहयोग गर्दै आएको एउटा अन्तराष्ट्रिय एनजिओ खानेकुरा मुखमा हाल्दा स्वास प्रश्वास बन्द भएर बितेको बालकको ज्यानको लागि जिम्मेवार हुँदैन। विदेशीहरूमाथि आरोप लगाउँन सजिलो छ तर सन्चालक समितिका अधिकाँश सदस्य नेपाली नागरिक छन्।

एक निष्पक्ष छानविनले केवल दोषारोपणमा मात्र होइन त्यसभन्दा धेरै कुराको परिक्षण गर्नुपर्छ तर त्यही विन्दुमा रहेर छानविनले स्वास प्रश्वास बन्द भएको सो घटना पनि भैपरी आएको भनेर निष्कर्ष दिन सक्दैन। मेरो जानकारी अनुसार नेपालका ग्रामिण क्षेत्रमा हामीले ति युवा चिकित्सकहरूलाई पठाउँनु अघि उनिहरूलाई तयार पार्न के गर्नु पर्छ भन्नेतर्फ ध्यान दिनुपर्छ। म जहाँ जान्छु त्यहाँ म एमबीबीएसको कोर्श र इन्टर्नशिपमा पहिलो नजर लगाउँछु। मैले यो जानकारी पाएको छु कि पीजी तालिममा नजाउन्जेल नेपालमा कसैले पनि एडभान्स्ड कार्डियाक लाइफ सपोर्ट वा पिडियाट्रिक एडभान्स्ड लाइफ सपोर्टबारे अध्ययन गरेका हुँदैनन्। अधिकाँश चिकित्सा कलेज वा नर्सिङ् स्कूलमा एकमात्र सिपिआर डोल हुन्छ र नर्स तथा चिकित्सकहरूले यसको प्रयोग गरेका हुँदैनन्। उनिहरूले कृतिम स्वास प्रश्वासको लागि साइकोमोटर चलाउन दक्षता हासिल गरेको कसैले हालसम्म देखेको पनि छैन। स्षष्ट रूपमा यो खाडल वा ग्यापलाई पुर्नु आवश्यक छ। चरीकोटमा पीजी तहसम्मको योग्यता हासिल गरेका चिकित्सक थिएनन्। सबैतिर यस्तै परिस्थिति देखिन्छ। यसकारण म यो निष्कर्षमा पुगेको हुँ कि चरीकोटका चिकित्सकहरूले आफ्नो कर्तव्य निर्वाह गरेका थिए। उनिहरूले सकेसम्म राम्रोकाम गरेका थिए।

पाठ्यक्रमलाई परिमार्जन गर्नु आवश्यक छ

एमबीबीएस तालिमको चौथो बर्ष र इन्टर्नशिप वर्षलाई स्तरोन्नति गर्नु आवश्यक छ जसले गर्दा यो तालिम पुरा गर्नेहरू सबैले सफलतापूर्वक सामूहिक कृतिम स्वास प्रश्वास विधि सन्चालन गर्न सक्नेछन्। सिपिआर, एडभान्स लाइफ सपोर्ट र पेडियाट्रिक लाइफ सपोर्ट तालिम पुरा नगरून्जेल कुनैपनि चिकित्सकलाई ग्रामिण क्षेत्रमा पठाउँनु हुँदैन। नर्सहरूको हकमा पनि त्यसै गरिनुपर्छ। कुनै कुनै अस्पतालहरूमा त एकजना नर्स पनि सिपिआर दिन वा बालकको मुखमा अड्केको कुरा निकाल्न सक्षम रहेको पाइँदैन्। नर्सहरूलाई कहिल्यै तालिम दिइएको छैन। चरीकोट पनि यस्तो एउटा ठाउँ भएजस्तो लाग्छ। घटनास्थलको सबभन्दा नजिक रहने मानिसमा त्यो क्षमता हुनुपर्छ, र त्यो काम वरिष्ठ चिकित्सकहरूका लागि भनेर राख्नु हुन्न। चरीकोटमा सक्सन वा व्याग भल्भ मास्क उपलब्ध थियो वा थिएन भन्ने समेत हामीलाई थाह छैन। ति उपकरणहरू अस्पतालमा विरामी भर्ना गरिएको वार्डमा नभै आकस्मिक कक्षमा मात्र राखिनु अक्सर अनौठो कुरा होइन ।


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.

स्वास्थ्य मन्त्रालयले राष्ट्रिय स्वास्थ्य योजनामा सशोधन गर्नु आवश्यक छ

मैले यो कुरा गतवर्ष प्रस्ताव गरेको थिएँ जतिबेला मैले आफ्नो कार्यक्रमलाई अगाडी बढाउँने र नर्सिङ् स्कूल र कलेजहरूलाई यो विधि अपनाउँन सघाउँने उपायहरूबारे सोचविचार गर्दै थिएँ। नेपालको राष्ट्रिय स्वास्थ्य योजनामा उल्लेखित ति दक्षताहरू समावेश नभएसम्म लगानी खोज्नका लागि कुनै पनि काम कारबाही नगरिने कुरा थाह पाउँदा म अचम्म परेको थिएँ। त्यसो होइन। थप कुरा के हो भने उक्त योजनालाई अध्यावधिक गर्न सघाउँन सक्ने अधिकाँश प्रशासकहरूलाई कृतिम स्वास प्रश्वास भनेको के हो भन्नेकुराको समेत यकिन जानकारी छैन्। न त यसलाई प्रभावकारी रूपमा सिकाउँन अबलम्बन गरिनुपर्ने विशेष सिकाई विधिबारे नै जानकारी छ। मेरो आफ्नै कोर्समा पनि नकारात्मक परिणाम आउँदा बखत हामी परिस्थितिलाई चर्कन नदिएर मत्थर पार्ने कला सिकाउँछौँ अर्थात त्यसबारे काउन्सिलिङ् गर्छौँ। चीनमा एमबीबीएस अध्ययन गरेका नेपाली विद्यार्थीले प्रयोगात्मक दक्षता हासिल गर्ने मौका अझ कम पाउँछन्। यस्ता तालिमको कमिका कारण नेपालमा तालिमप्राप्त गरेका चिकित्सकहरूका लागि भारतमा वा अन्य देशमा थप विशेषज्ञता हासिल गर्न हुने प्रतिस्पर्धामा नाम निकाल्न अझ गाह्रो हुन्छ।

यदि स्वास्थ्य मन्त्रालयले राष्ट्रिय स्वास्थ्य योजनाको लक्ष्य अध्यावधिक गरेर कृतिम स्वास प्रश्वास क्षमतामाथि ध्यान केन्द्रित गरेर चिकित्सा कलेजको पठन पाठन वा इन्टर्नशिप वर्षमा त्यसलाई समावेश गरेमा यो क्षेत्रमा विदेशी लगानी निर्देशित हुने सम्भावना रहन्छ र नेपालको लागि यस्तो लगानीको प्रतिफल लाभदायक हुनेछ।
आगामी वर्षहरूमा नेपालले नयाँ चिकित्सकहरूलाई दूर दराजका ग्रामिण क्षेत्रहरूमा चिकित्सा सेवा उपलब्ध गराउँने उपाय स्वरूप ति ठाउँहरूमा पठाउँने सोच विचारलाई निरन्तरता दिनेछ। हामीले उनिहरूलाई सफल तुल्याउँने र सुरक्षित रूपमा काम गर्नसक्ने बनाउँने क्षमता भरिदिनु पर्छ। समस्या समाधानका लागि यो एकमात्र रणनीति होइन तर यो एउटा महत्वपूर्ण कदम हो। 


Joe Niemczura, RN, MS अमेरिकाबाट आउँनु भएको हो र उहाँले नेपाली नर्सिङ्को लाइसन प्राप्त गरिसक्नु भएको छ। उहाँ CCNEPal मा Principal Faculty हुनुहुन्छ र उहाँले आफ्नो कोर्शको सिलसिलामा ९० वटा क्लास मार्फत २८८५ नर्स र चिकित्सकहरूलाई पढाइसक्नु भएको छ। उहाँको दोश्रो पुस्तक The Sacrament of the Goddess एउटा उपन्यास हो। यसमा शिशु जन्माउँने क्रममा नचाहँदा नचाहँदै ज्यान गुमाएकी एकजना आमाको मृत्युको विषयलाई लिएर क्रुद्ध भिडले चिकित्सकमाथि गरेका दूर्व्यवहारको कहानी उल्लेख गरिएको छ। Niemczura ले नेपालमा स्वास्थ्य सेवा क्षेत्रमा कामगर्ने मानिसहरू विरूद्ध हुने गरेका हिँसाबारे गहन अध्ययन गरेर त्यसलाई उपन्यासमा उतार्नु भएको छ। त्यसबारे थप जानकारी Amazon वा Vajra Books ठमेलबाट पाउँन सकिन्छ। थप जानकारीको लागि उहाँको ब्लग मा हेर्नुहोस्।

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About the Charikot Incident, Sept 28th 2016

Sept 30th update and correction

The post below was written shortly after I learned of the events in Charikot. Turns out the patient was two-and-a-half years old, not a newborn. There have been other developments – all the doctors have left; the local political authorities did not seem to have taken the proper action; the video has been roundly condemned;  the hospital is presently shutdown; and  the family has expressed the idea that they did not want such a drastic outcome. The Ministry of Health has sent a three-person committee to Charikot.

It’s more than I can keep up with. I need to resist the urge to relay each new development breathlessly before the next step develops.

For me, the bottom line remains that the young doctors needed more preparation for their posting, then they got. For five years I have worked to promote the need to teach situational awareness. I am hoping that if there is any good to be gained from, it will be when the Ministry of Health, The Nepal Medical Association, and the medical colleges take a good look at how to introduce this into the curriculum for all MBBS doctors in Nepal.

Charikot Incident

In Charikot, Dolkaha district of Nepal, the hospital staff are under investigation due to an incident in which a newborn baby (correction: 2 1/2 year old) died after being brought to ER. It is not unusual to have a person die in an Emergency Room; in this case the family reacted by blaming the hospital staff and threatening them. This too, is not unusual. Any Nepali nurse can tell you this or that incident in which this was a problem.

In Charikot, none of the staff seem to have been hurt (we await more details) but the whole incident was traumatic.  The local authorities are investigating.

I’ve been through Charikot, on  a “local” bus. It was the last east-bound bus of the day. We were all headed to Manthali.  The bus was overfull. Such buses always are. The bus crew did not want anybody on the roof. About a dozen guys wanted to ride the roof. There was an argument and a lot of shouting and jostling. The guys got on.  Rural Nepal is not always Never Ending Peace and Love.

Back to the incident at hand

start with a recent video:

(update: evidently the acting district officer was unable to disperse a crowd of 300 people who had gathered, and ordered the doctors to do this, recording this video. This is unprecedented in Nepal). The hospital in  Charikot was damaged in the second big earthquake of 2015, May 6th, when the epicenter was in Dolakha district. Since then, it has been a project of the US-based NGO, “Possible Health.”

Here is the website of Possible:  They are doing good work in a critical sector. The NGO is “foreign” but the staff is Nepali. ( update: and most of the members of their Board are Nepali).

The link above includes a description of their work in Charikot and rebuilding health posts in that region. There is an informative Q & A.

Press Release

Since the incident, there is a press release from Possible Health:


This describes the incident. In Nepali of course! I do not presently have an exact translation.

My friends from Possible were shocked.

For me, the story is familiar. A critically ill person is brought to the ER. The family demands the staff to do something, but it is too late and the victim dies. Somehow the family demands that the staff be held responsible. Things spiral out of control.

A lot of my work in Nepal is to prepare nurses and doctors for appropriate handling of this situation, and in fact, CCNEPal has trained 2,885 nurses and doctors as to how to respond when this exact thing happens. We do this by incorporating a scenario-based approach to the principles of counseling the patient party.

Critical fact!!!!!!!

This happens all over Nepal. It is not the first time. It is more highly publicized than most of the other  times.

One important thing to know is – the doctor(s)  will always be blamed regardless of the facts of the case. Anger is a predominant response in acute grief in Nepal. These incidents have a history of happening throughout the country and they are depressingly familiar.

My second book about Nepal, The Sacrament of the Goddess, depicts just such an event and it’s the climax of the book.


Nepal is Hindu and Buddhist. This novel explores the issue of how people reconcile with anger and violence in a country known for peace and love.

Preparation is critical for an effective response

It takes courage to be an ER nurse or ER doctor in Nepal.  You need more than just the ACLS protocols.

Some hospitals already train their staff. They are considerably less likely to have this problem. Or at least it will be mitigated.

First, take a look at this YouTube playlist:

Past blog entries with practical suggestions

next, on this very blog are a dozen or more entries on the subject of how to
prevent thrashing and to maintain an secure environment.


MBBS students participating in a role play. Here, they are security guards bringing an unresponsive “victim” for emergent care. Other participants play the role of distraught family.


If you only read one, it should be this:

ten rules:

My response after the incident at Patan Hospital:

Hospitals during Nakibanda:

Campaign to teach situational awareness:

I’ll try to follow the outcome of this incident. I hope it does not deter Possible from continuing the excellent work they are doing.



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Announcing “The Himalayan Zap Trek 2017” GoFundMe campaign

Mention Nepal and everyone thinks of #Everest.


at the end of the time in Biratnagar, the farmers planted the entire paddy behind the guest house, as well as others. during this period, it’s like the hospital is an island in a large lake that’s only six inches deep. I left one day before the torrential rains began for monsoon 2016.

Thirty million people live in Nepal, and 99.999999999% of them do not live anywhere near Everest.  Nepal also has a large rice-growing region, where western tourists are rarely seen. See the above photo!

Since 2011, CCNEPal works on a project to improve health care for those people.

Maybe that’s a little vague. Try this:

Imagine a hospital with no Code Blue team. Nobody knows CPR, they don’t do “Rapid Response Teams” and if a patient crashes due to a predictable complication after routine surgery, it’s a hit or miss proposition as to the outcome. That’s the situation for most hospitals in Nepal.

It’s easy to say “Oh, it can’t be helped. Nepal is a low income country after and they are used to a short life span.”

CCNEPal’s answer? Yes it can be helped! Our answer is simple: we teach critical care skills in a two- or three-day intensive course based on the ACLS course of the American Heart Association (we adapted the content to fit Nepal and it is not the “official” course). We have taught ninety sessions, and given certificates to 2,885 nurses and doctors in that time in many regions of Nepal. We have created widespread awareness of the training and recognition of the need for this training after five years of work.

In 2017 the plan is to build on this work. In the past CCNEPal was privately funded but we need to find a new source of funding. So – The Himalayan Zap Trek 2017 was born.

What is a “Zap Trek”?

“Zap” is the sound made by a defibrillator when you shock a dying patient. (actually, “zork” is a more accurate term, but “zap” is used by doctors and nurses worldwide, so zap it will be). “Zap” is an onomatopea.

A “trek” is a long-distance hike in Nepal, such as the “Annapurna Trek” – considered to be the finest such experience on the planet and a lifetime bucket list item for any diehard outdoorsperson.

CCNEPal teaches how to defibrillate; we travel; therefore the name was born.

CCNEPal eschews trendiness, but – Zap Trek 2017 will have a trendy appeal.

GoFundMe site.

If we can get funding, our goal is

-to stay in Nepal for five months;

-teach 2,000 people;

-provide materials and equipment for hands-on training.

-teach at ten or more Medical Colleges, including every Medical College outside Kathmandu Valley; and

-improve our network of on-site trainers in all the large cities of Nepal, so that the training becomes embedded everywhere. If you browse this site, you will see our track record of success, but more needs to be done. For this reason, we have set up a GoFundMe site.

We’ll post a detailed budget breakdown in coming days.

Please share this widely.


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The Three-legged Stool of Global Health Nursing – for October 15th in Boston!

Nurses: A Force for Change: Improving Health Systems’ Resilience

above is the title of the Oct 14th and 15th 2016 meeting of Boston’s Global Health Nursing Caucus (in Boston of course!) and the event can be found at: It’s co-sponsored with SEED Global Health.

Lightning Talks between 11 and 12:30  the 15th

They’ve made space for “lightning talks” – five to ten minute presentations modeled after the popular “Ted Talks” – a chance for the speaker to present just one idea. This is a great idea – the best meetings are ones where you can learn from the other attendees as much as from the presenters. This gives people the chance to figure out who is in the audience next to them.


these ladies are wearing “paranda” – a traditional tassel or hair extension. I got a lot of these for the C.U.G.H. meeting last spring.I have some remaining and I’ll bring them. Want one? just ask!

The Three-Legged Stool of Global Health Nursing

That’s the title of my lightning talk. I needed to focus on just one idea, and that’s what I chose. It’s the most elegant way to think of how to advance nursing in Low Income Countries. Some projects succeed, some fail. Sometimes you see things that you want to change, and which can’t be changed no matter what you try to teach or do or model or support.

The three legs compose a “Schema” of interrelated phenomena. If you try to change one, without addressing the other two, your stool will not be level, and may collapse when you try to sit on it…….

First leg is culture and the role of women.


medical colleges in Nepal are working on “gender balance” but nursing is still female. The solidarity to be found in an all-female work group in Nepal is inspiring. There is an upside to go with the downside….

Second Leg is the nursing education curriculum and system.


seen on a classroom whiteboard of a PCL nursing school in Kathmandu, Nepal. Students there are regimented; they learn to love it, and even if they don’t it molds them a certain way…..

Third leg is the setup of nursing service. To understand nursing in a low income country, you must understand Functional Nursing – click here –

Study the above! ( don’t confuse it with the argument about “functional vs. dysfunctional,” that’s a whole ‘nother animal entirely).

got it?



some three-legged stools are fancier than others. Here is one with “patina” – age marks that make it beautiful.

How does it work? well, my best examples are from Nepal, of course since that is where I work.

The nursing service system is organized to provide “Functional Nursing” which is to say, task-based nursing. The hospitals are not staffed to provide individualistic nursing care such as we would think of with “primary nursing” or “team-based nursing.” Oh, individualized nursing care can happen, but it is on a  hit-or-miss basis.

The educational system (especially of the PCL level) teaches functional nursing. As long as the hospitals want and need functional nursing,  the PCL nurses will provide it.

Functional Nursing depends on the idea that nurses do what they are told and don’t generally ask questions. Functional Nursing is a way to get the mandatory tasks done with the least number of people – in that respect functional nursing is not good or bad, it is just  “is.”

which brings us to –

The role of women in the culture.  In Nepal, the traditional role in involves deferring to the judgment of males, or deferring to the doctor, or deferring to who ever is “senior.” In that respect, functional nursing is elegantly matched to the culture.

If you as a foreign colleague see an opportunity to “improve things,” you need to resist the urge to jump in and implement something in one of the three legs until you have assessed the impact on the other two legs. This schema can be used to assess whether a given intervention is “sustainable.”

That’s enough for ten minutes, don’t you think? If I were to exhaust the topic, I could roll it on into about eight hours of presentation.

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