Revised Schedule for Summer sessions of CCNEPal 2017


Three weeks shortened from end of schedule

Updated June 24th

I need to update my schedule. I cancelled all the previously-scheduled sessions outside Kathmandu Valley  after June 23rd. I gave the talk in Kirtipur, and will deliver the sessions listed below. I need to do this because in USA, my father will be finishing his course of physical therapy treatments, and I will return there when he is discharged from the Rehabilitation hospital. My brother requested me to go there and so – I will return to USA three weeks early.

Here are the remaining sessions:

15. June 25th, 26th & 27th, 3-day course at Norvic (30+) ( added).

16. June 28th, 29th and 30th, 3-day course at Norvic (30+).

I added the final sessions at Norvic because they had a problem – the ones who took my sessions were extremely enthusiastic and created a sort of jealousy among those unable to register. ( some body does need to cover the patient-care duty, after all). And so we will train more persons. Also, Norvic has been “fun” and I loved the people I met there. It’s a fine hospital.

I also need to “take time and smell the incense….”

I fly out at 0815 July 2nd.

Attitude of Gratitude

I wish to extend my thanks for all the enthusiastic participants who recognize the usefulness of the courses I offer. I thrive on the positive energy. Together we can improve patient care during critical situations throughout Nepal. I hope to return in 2018 and collaborate with all my Nepali friends.

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Don’t put 10 cc air in the cuff of any endo-tracheal tube


Use the minimal-leak method instead. Described below.

parts of an endo-tracheal tube. (this is of a newer variety with built-in suction port to prevent micro-aspiration). from http://www.derangedphysiology.com/main/core-topics-intensive-care/mechanical-ventilation-0/Chapter%201.2.3/endotracheal-tube-detail

In a recent blog, I got lots of hits but very few clicks on the actual video. I decided to rewrite this to focus only on this one specific issue.

Summary:

Here is a policy and procedure from a major teaching hospital in Texas, USA.

https://www.utmb.edu/policies_and_procedures/4230146

UTMB RESPIRATORY CARE SERVICES PROCEDURE – Minimal Occluding Volume (MOV) or Minimal Leak Technique Policy 7.3.49 Page 1 of 4 Minimal Occluding Volume (MOV) or Minimal Leak Technique Formulated: 11/92 Effective: 11/02/94 Revised: 11/03/14

Continued next page

Minimal Occluding Volume (MOV) Purpose To standardize the method of minimal volume of air in the endotracheal/tracheal cuff that will allow optimal sealing of the airway.
Scope  All intubated patients will be assessed for proper volume/pressure in endotracheal cuffs with each ventilator assessment.

 All tracheostomy patients not utilizing a foam-filled (bivona type) cuff volume/pressures will be monitored on a routine basis.

 The acceptable intra-cuff pressure is less than 25 mmHg.

Audience Respiratory Care Practitioners employed by the Respiratory Care Services Department with the understanding of age specific requirements of the patient population.
Equipment  10cc syringe

 Stethoscope

 Cuff pressure manometer

 Three-way stop cock

 OR Cufflator cuff inflation device

 Manual resuscitator and mask

Procedure
Step Action
1 Technique for MOV

 Suction the patient airway and oral pharynx to prevent possible aspiration of retained secretions.

 Place your stethoscope diaphragm over the laryngeal area and inflate cuff until all air leak is gone.

 For Positive Pressure Ventilation, remove small increments (0.25-0.50cc) of air from the cuff until a small leak is heard at the point of peak inspiratory pressure (PIP). Check tidal volume to insure adequate ventilation and inflate cuff until all air leak is gone.

 For spontaneous ventilation or CPAP, remove small increments of air (0.25-0.50cc) from cuff until a small expiratory leak is heard (usually in early or mid exhalation). Inflate until all air leakage is gone.

Here is a video showing exactly how to do it:

What if you use too much air?

Using the 10 cc is wrong because it causes “tracheal malacia” and post-extubation stridor. the trachea gets stretched at the point of balloon contact and collapses when air moves out. It can also contribute to tracheal-esophageal fistula. In other words, too much air in the cuff will harm the patient.

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You are invited to a talk June 21st about Thrashing, plain and simple


Who: Joe Niemczura, RN, MS Principal faculty of CCNEPal

What: Public lecture Violence Against Health Care Workers in Nepal and what can be done about it

When: Wednesday June 21st from 2 PM to 3, then Q & A afterwards

Where: Sociology Department, Tribhuwan University, Kirtipur, Nepal

Why: “Thrashing” is a big problem in South Asia including Nepal.

Abstract: Violence against health care workers is a problem throughout South Asia and has reached a level where doctors in India have promoted an act of parliament to allow doctors to carry handguns to defend themselves. (not yet adopted).  In  Nepal, this issue gains publicity when sensational reports appear in the newspaper, often reaching the level of communal involvement, but the frequency seems to be seriously under-reported, and there is pressure by many stakeholders to minimize the severity of the issue.  CCNEPal is a small group that delivers workshops on critical care skills to doctors and nurses in Nepal since 2011, and we include activities to raise situational awareness among young doctors to prevent difficulties with the patient party. This presentation will address the issue and share future directions to mitigate the problem in Nepal. It will take place at the D

from Kathmandu Post after a thrashing incident. These are not isolated and the problem exists throughout South Asia. Let’s talk about it.

epartment of Sociology and the media and general public are invited.

For further information, call 98010 96822

or email joeniemczura@gmail.com

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about mechanical ventilator patient in Nepal


Update:  This one got hundreds of hits, but few clicks on the video and I think I needed to be more focused. I made a separate entry to focus just on the ET tube cuff volume issue.  CLICK HERE for the new one! http://wp.me/p1pDBL-1smBe sure to click on the video!

In this blog, the directions to ET Tube cuff volume amount are near the end. Keep reading!

I think I might do a series of blogs for nurses and Medical Officers in Nepal.

The Snake Man

Yes, that’s me but I don’t take myself as seriously as the title may imply. This is the tenth anniversary of the episode that happened in Tansen at Mission Hospital that gave me the nickname “The Snake Man” and pioneered the use of mechanical ventilation at that place. It was one of the epics of my entire life and the story is told in my first book.

In 2007 I did something that led to one of my nicknames – “the Snake Man” – you can read about it in my first book.

I didn’t actually know anything about snakes or snakebite, at the time. These days I teach about Cardiac resuscitation when I am here in Nepal, but I am sometimes asked if I would talk about nurses responsibility in mechanical ventilation. So recently I spent some time with some nurses. Instead of giving a formal talk I started off by asking questions and having them show me some things to make sure I knew what it was they were doing. I try not to re-teach people stuff they already know.

RT

For my readers not in Nepal, be advised there is no “Respiratory Therapy” profession in Nepal. Ventilators, and indeed critical care, are in the hands of “anesthesiologists” who after all, place ET tubes during surgery. Except of course when they don’t – in many small hospitals anesthesia is supplied by anesthesia technicians. So the doctors are the ones who do the vent settings.

A Canadian friend named Eric Cheng is involved with a small NGO named “Respiratory Care Without Borders,” giving workshops on this field. I don’t think he’s been back lately – RTWB now works in several dozen countries. I am going to browse their site to see what they recommend for books, etc.

This is another example of clinical issues where the nurse needs to be assertive. For example, in the USA if the tube is dislodged, the nurse removes it, uses a Bag-Valve-Mask, and calls the doc. Not every nurse in Nepal is confident or assertive enough to feel comfortable with this decision. Are you? Would you be?

Not every nurse or MBBSW doc knows how to use a BVM for that matter. I specifically require them to learn skills related to this. Including how to clean the darn thing. I wrote an eight-page policy and procedure on this a few years back.

The Pen Drive

In any case, I have decided to create another folder on the pen drive and load some documents and articles there. It’s been awhile since I updated the stuff I give to session participants. I will distribute it from now on. Bring a pen drive to class!

On the internet I found:

a Booklet titled  “Mechanical ventilation for Dummies”:

www.ucdenver.edu/academics/colleges/medicalschool/…/8-04-08%20McIntyre.pdf

Here are some video links I liked:

 How to assist at placing an Endotracheal tube (also known as “intubation”)

Here is another. This video goes over care of an endo-tracheal tube including oral care, documenting the proper depth, and repositioning:

Minimal Leak method

Cuffed ET tube

DO NOT PUT 10 cc air in ET Tube cuff. Choose the amount carefully. Use “minimal-leak” procedure:

People asked how much air to put into a cuff. I showed the group how to decide how much air goes into ET tube cuff, using “minimal leak” method.  I think it worthwhile to highlight the need for this specific procedure:

 

Fifteen minute basic and excellent introductory lecture, first of a series:

Phasing in

There is a zen associated with effective assessment of ventilation. I always referred to this as “Phasing In” but it’s actually got a more technical name, “patient-ventilator dis-synchrony.” It’s when the patient fights the ventilator. A person on a ventilator is ideally mellow and happy; if they are not, you have to figure out why!

Here is an excellent video from Australia about “Patient Ventilator Dis-Synchrony” also known as “phasing in”

I will add to this over coming days, but – this is a start.

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CCNEPal critical care training update June 7th 2017


At Charak Hospital we do our small-group scenario practice on the roof, and it reminds me of the “Rooftop Concert” – last public performance of the Beatles.

June 7th update

We’re about to begin this year’s only session in Pokhara. This is my fifth trip here – I spent two weeks in 2016 and led five sessions. Charak Hospital is the venue, and the training hall is on the roof of the building, in full view o fthe Annapurna Range (on a good day).

 

For those of you new to this blog – welcome! This project began in 2011 with three goals:

  1. train Nepali nurses and doctors in techniques of Advanced Cardiac Life Support based on the American Heart Association ACLS class (plz note that this is not the “official” class – in previous blog entries I describe in detail the hows, whys and wherefores). status: about 3,000 people have completed the course to date in about 97 sessions.
  2. bring attention to the fact that there is such as thing as ACLS and that it is needed. Seems odd to say, but at the beginning there was tremendous resistance to the idea that the need existed. Status: Now there is wider acknowledgement of the utility of this training. Especially for nurses. This training has elevated the role of nursing at the bedside in Nepal.
  3. create a movement within Nepal to “own” this training, not just at PG level, but during the crucial transition from MBBS to intern. It is the young doctors at bedside, often in the middle of the night or out in a rural area, who need the skills taught by this course. status: some medical colleges are sending 100% of their students to CCNEPal; others have unpgraded their training to teach in themselves. CCNEPal wrote a concept paper to strengthen the Nepal Health system and it’s right here on this blog.

You are invited to browse past entries (there are more than 200) to read all aspects of this project.

Here is the remaining schedule:

9. June 7th, 8th, 9th – 3-days course for nurses in Pokhara at Charak Hospital (38!)

June 10th – travel Pokhara back to Chitwan again. The bus goes through Tanahun, a beautiful section of Nepal.

10. June 11th, 12th; Batch #1 of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

11. June 13th,14th; Batch #2 of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

12. June  15th, 16th; – Batch three of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

June 17th – travel back to Kathmandu

13. June 18th, 19th 20th – 3-days course for nurses at Norvic Hospital (30)

June 21st reserved for special event in Kathmandu. At 3 PM that day I will deliver a one-hour guest lecture to the sociology department of T.U. in Kirtipur.

14. June 22nd 23rd, 2-days course for Medical Officers at Norvic (30)

June 24th – travel – back to Bharatpur of course!

15. June 25th, 26th – Batch #4 of four 2-days session for CMC interns (final) (30)

16. June 27, 28; 29th Nurses at Narayana Sandiak Hospital Bharatpur (30)

June 30th and July 1st – If I haven’t gone to Sauraha birdwatching by now I will surely do it. My older brother is an avid birdwatcher and I will look for them in his honor!

July 2017

17. July 2nd and 3rd – Batch #2 of three at CMS for MBBS (30)

18. July 4th and 5th _ Batch #3 of three at CMS for Medical Officers at SMC (“Purano”) (30)

revised total is about 450 if all goes as planned. Seven travel days.

19. July 6th, 7th and 8th – travel. Then two days in Kathmandu to take in the wonders of the city – to stop and smell the incense – and buy souvenirs for my friends and supporters.

20. July 9th, 10th, 11th, National Burn Center, Kirtipur (nurses) (30)

21. July 12th – 13th – National Burn Center, Kirtipur, 2-day for interns (30)

My goal is to teach until I get on the plane! I leave Nepal July 14th at 0815 in the morning from Kathmandu. My Nepal phone number is now working 98010 96822 plz don’t call after 9 PM

email me at joeniemczura@gmail.com

Dates are subject to change. If you are interested to host me or wish to clarify – my Nepali number is now working – 98010 96822 please do not call after 9 PM

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May 25th Summer 2017 updated schedule


May 2017

1 & 2. May 18th, 19th – two one-day trainings at MC are now in the history books. 18 and 18.

May 20th – travel to Palpa

3. May 21,22, 23 – Batch #1 3-days course for nurses at Lumbini Medical College, Palpa (37, completed)

4. May 24,25, 26 – 3-days course for nurses at LMC batch #2 (39, completed)

May 27th – travel back to Bharatpur

5. May 28, 29 30 – 3-days course for nurses at CMC Bharatpur batch #1 (34)

June 2017

6. May 31st, June 1st, 2nd – 3-days course for nurses at CMC batch #2 (34)

June 3rd – day off. Maybe I will ride an elephant, maybe I will go to Sauraha and bird-watch with a guide. My elder brother loves birdwatching and has helped me to appreciate the sport. I like to keep my observation skills honed to a fine edge like the best kukri.

7. June 4th, 5th  – Batch #1 of three. 2-day course at College of Medical Sciences (“Purano”) for MBBS (30)

8. June 6th – travel to Pokhara. via Mugling of course!

9. June 7th, 8th, 9th – 3-days course for nurses in Pokhara at Charak Hospital (30)

June 10th – travel Pokhara back to Chitwan again.

10. June 11th, 12th; Batch #1 of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

11. June 13th,14th; Batch #2 of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

12. June  15th, 16th; – Batch three of four 2-day session for MBBS interns and medical officers at CMC in Bharatpur (30)

June 17th – travel back to Kathmandu

13. June 18th, 19th 20th – 3-days course for nurses at Norvic Hospital (30)

June 21st reserved for special event in Kathmandu.

14. June 22nd 23rd, 2-days course for Medical Officers at Norvic (30)

June 24th – travel – back to Bharatpur of course!

15. June 25th, 26th – Batch #4 of four 2-days session for CMC interns (final) (30)

16. June 27, 28; 29th Nurses at Narayana Sandiak Hospital Bharatpur (30)

June 30th and July 1st – If I haven’t gone to Sauraha birdwatching by now I will surely do it. My older brother is an avid birdwatcher and I will look for them in his honor!

July 2017

17. July 2nd and 3rd – Batch #2 of three at CMS for MBBS (30)

18. July 4th and 5th _ Batch #3 of three at CMS for Medical Officers at SMC (“Purano”) (30)

revised total is about 450 if all goes as planned. Seven travel days.

19. July 6th and 7th are unbooked at present – I’ll be in Bharatpur…..why not?

July 8th – probable travel day, to Kathmandu.

20. July 9th, 10th, 11th, National Burn Center, Kirtipur (nurses) (30)

21. July 12th – 13th – National Burn Center, Kirtipur, 2-day for interns (30)

My goal is to teach until I get on the plane! I leave Nepal July 14th at 0815 in the morning from Kathmandu. My Nepal phone number is now working 98010 96822 plz don’t call after 9 PM

email me at joeniemczura@gmail.com

Dates are subject to change. If you are interested to host me or wish to clarify – my Nepali number is now working – 98010 96822 please do not call after 9 PM

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CCNEPal concept paper for Strengthening a decentralized health system in Terai of Nepal May 15th 2017


Notice of Funding Opportunity

The Ministry of Health and USAID have proposed a new project in Nepal which will focus on “Health Systems Strengthening” over a five year period.  To inform the groups that will apply for the funds, USAID published a very interesting document called Notice of   Funding Opportunity (NFO) describing the goals.

Three main Goals

  1.  Improved access to and utilization of equitable healthcare services
  2. improved quality of healthcare services, and
  3. Improved health system governance, including within the context of decentralization and federalism ( from page 6).

https://www.grants.gov/web/grants/view-opportunity.html?oppId=293419 At the beginning the NFO includes a summary of USAID-funded programs in Nepal. The portfolio of current USAID projects in Nepal was authoritatively summarized. If you are interested in the health status of Nepal, this is a must-read.

CCNEPal will not be applying

The USAID rules require that anybody applying for this grant show a track record of three prior grants of ten million USD or more, and also meet requirements to document where the money went and how the program was evaluated. For that reason, CCNEPal is not eligible to apply. Most Nepal-based entities are also ineligible unless they have a foreign partner.

What the 2017 NFO has minimized or omitted

First, a few facts. Twenty one of the proposed districts in the service area are in the Terai, the flat part of the country bordering India.

revised_suaahara_map_1

Suaahara is the main USAID project for nutrition and MCH n Nepal. This map does not depict the relative population density of the various districts.

Fifteen million people (half the population of Nepal) live in Terai. When USAID started work in Terai there were no medical colleges and few nursing colleges. USAID has worked there for years to develop nutrition programs and a system of Community Health Workers (CVHWs).

Why These areas?

This becomes easy to explain if you were to superimpose another map over the above:

stunting_in_Nepal

The Government of Nepal prioritizes these areas due to childhood stunting. “Food Security” or the lack thereof, has lifetime consequences. I wrote about this in another blog  http://www.dailykos.com/story/2015/9/28/1425296/-The-Siege-of-Kathmandu-day-five-special-food-shortage-issue-Sept-28th last year.  The above graphic comes from a study published in 2015. http://pubs.sciepub.com/ajphr/3/2/7/

infographic of medical education in Nepal 5

Half the population of Nepal lives in Terai. All the medical schools in Terai are non-governmental, i.e., “private” – and I should add, in this region of Nepal there is a higher per centage of Hindi speakers.

Over the past ten years there is dramatic change. Today there are nine medical colleges in Terai alone, producing about three hundred and fifty new MBBS doctors per year just from this region. (there are thirteen other medical colleges in Kathmandu and elsewhere. Nepal produces about six hundred new doctors a year overall). The strategic assumptions of improving access to health care in rural Nepal as outlined in the NFO is written as if this system does not exist.

The current USAID projects are focused on Maternal-Child Health (MCH) and this proposed project will continue to focus on reducing MCH mortality.

PHC-nepal

Map of health Posts in Nepal. These are primary care centers. from: http://medchrome.com/extras/facts/health-system-nepal/

Any plan to improve health systems strengthening needs to include the medical colleges and needs to include a plan for the doctors they produce, especially the  newly-graduated doctors.  A quick websearch turns up articles from WHO as far back as 1996 http://www.who.int/hrh/en/HRDJ_2_1_05.pdf  that explore the idea of how many doctors Nepal needs. At that time, there were only two medical colleges in the entire country. The career path of new doctors in Nepal has been an ongoing discussion, since the government subsidizes medical education yet most new doctors are reluctant to practice in rural areas.  CCNEPal has worked with newly-graduated MBBS doctors to provide confidence-building skills.

Spoke-and-wheel approach

In a decentralized (federalized) health system, the stated goal of Nepal’s Ministry of Health (MoH) and USAID is to support a spoke-and-wheel arrangement, where there is a referral center in each province and the smaller outposts refer patients to the larger center when warranted. This trend is already occurring. The flow along the spokes is conceptualized as one-way, with patients from the periphery flowing inward to each referral center. What is needed is to build a two-way system where medical knowledge is shared from the regional center outward. This is presently not happening enough.

What is the system to train new doctors in Nepal?

MBBS education is set up differently than medical school in USA.

MBBS is an undergraduate degree and is focused on reading and book work. All learning is in a very traditional classroom. There is new interest in “problem-based learning” but even this is still very didactic. Students do not incorporate “bedside manner” into their education.

  1. Minimal clinical experience is given during the undergraduate study.  A person graduates from medical college but has never written a doctor’s order, participated in an actual emergency, spoken with a nurse, or prescribed a medication let alone examined for side effects.
  2. At graduation, a one-year internship is taken, during which the new doctor gets a crash course in practical aspects of being a doctor.
  3. After internship, MBBS doctors become a “Medical Officer” for a year or two.  Some continue as Medical Officers forever, as in government service ( “Lok Sewa”).
  4. after a year or two of being a Medical Officer the MBBS doc goes for Post-Graduate (“PG”) training, the equivalent of a Master’s degree after which they become an M.D., also known as a Senior Doctor.

Right at this present time (2017) there is now pressure for more medical colleges to be designated as sites for PG training,  as a natural consequence of turning the spigot a few years back to produce more MBBS graduates.

IMG_20150420_141846

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.

The weak link in the chain is the internship year and the transition to being a Medical Officer. In USA, every incoming new intern would already have a CPR course, and Advanced Cardiac Life Support (ACLS) a Pediatric Advanced Life Support (PALS), and perhaps other short courses that share a hands-on practical approach to patient care. In Nepal, none of these are offered until PG training. Until recently, the model has been oriented to primary care and the idea has been that Nepali doctors do not need these skills. As Nepal transitions to a system of regional medical centers, the skill level of both doctors and nurses needs to rise. CCNEPal once estimated that to reach a level of training equivalent to western expectations, 30,000 doctors and nurses around Nepal need to upgrade their skill level with these trainings.  This is a daunting scale of operation. Individual hospitals that offer these trainings are not equipped to expand programming to meet the need, and an organic system of train-the-trainer will take years to develop.

The main point is that systems need to be set in place for each medical college to address this weak link and train hundreds of persons each year. Each medical college needs incentives to promote “continuing education” for the doctors ( and nurses) in their region, that would not be the same as “PG education.”  This is still a new concept for Nepal.

Health Professions Education and Research Center in Bharatpur.

CCNEPal is a shoestring operation that focuses on one thing: continuing clinical education for doctors and nurses in Nepal.  CCNEPal focuses on this kind of training, but we are not the only ones who have recognized the need for continuing education at the level of intern. Chitwan Medical College (CMC) has already started their Health Professions Education and Research Center (HPERC) with the goal of providing the types of hands-on courses needed by MBBS interns as well as nurses. This was piloted in 2014 when CCNEPal trained CMC’s  entire graduating batch of MBBS docs in BLS and ACLS. CMC required their entire group to take the BLS and ACLS training with CCNEPal (120 individual MBBS doctors and 90 nurses). Students reported increased confidence in decisionmaking and clinical judgement as well as willingness to take the lead in emergency situations.  The CCNEPal course as presented also includes a segment on “situational awareness” that teaches counseling skills and emphasizes pro-active strategies to de-escalate during emotional situations.

What is ACLS? PALS? ATLS? NNR? AOLS?

These courses all use manikins and equipment to include psychomotor skills, teamwork skills, and knowledge of protocols in what we would call a nontraditional pedagogy approach, very different and new from the usual teaching methods of South Asia.  The JHPIEGO website characterizes this as “LDHF training” – Low Dose, High Frequency. These courses teach resuscitation protocols but also impart “soft skills” of leadership, judgement, team work, communication under stress, and priority setting. These courses have been universally required in USA for decades but are still quite new in Nepal.  In the past, these courses were reserved for the PG level but it is clear that first-year interns need this knowledge since they are on the front lines.

Other medical colleges have also worked with CCNEPal to train their graduates in this skill – Nobel (Biratnagar), Lumbini Medical College ( Palpa), Universal College of Medical Science ( Bhairawaha), College of Medical Sciences (like CMC, also in Bharatpur), and Janaki Medical College (Janakpur).  Many have begun to investigate ways to incorporate this mode of training into skill development of nurses and doctors. Nepali MBBS graduates who trained in China also need this skill set when they return as Medical Officers in Nepal.

CCNEPal’s concept

The proposed concept is to build on the HPERC idea from CMC and expand it throughout Terai. Part of the Health Systems Strengthening grant would be used to support a system of continuing education specifically targeted at interns and medical officers who will be in the rural areas, by setting up a HPERC at four or five selected sites in Terai or rural areas associated with Medical Colleges. Each would be equipped with manikins and simulation capacity for scenario-based learning. Most of the host sites in Terai are private colleges and would need to contract with the government to train personnel from the health posts.

The Medical City of Terai

It should be noted that Bharatpur is already known as The Medical City of Terai due to the cluster of hospitals and medical colleges along with government facilities. http://wp.me/p1pDBL-1ef

What would they teach?

Each HPERC would provide training in BLS, ACLS, neonatal resuscitation, Obstetric Emergencies, ATLS, mass casualty triage, and other courses based on certifications from existing western models, including Helping Mothers Survive from JHPIEGO. https://youtu.be/Hu8Na5gqnog Each would rely on simulation equipment and scenario-based training for these short courses. Each HPERC would develop their own faculty to teach these. Each would become the hub for all nursing schools to send their students without duplicating effort ( for example, there are fourteen schools of nursing in Bharatpur alone, only two presently enroll their nursing students in ACLS).

It should be noted that in the standard B Sc nursing curriculum in Nepal, 16 hours has been allocated for ACLS training since 2008, but this is widely ignored since most nursing faculty do not know what it is or what the teaching methods entail.  Nursing schools in Nepal do not have up-to-date skills labs or the system of knowledge needed to organize a skills lab.  If you go to my YouTube Channel, you can view videos of nursing skills lab from around the country of Nepal. https://www.youtube.com/playlist?list=PL05C15E3E2862A608

Future course content could be developed ( for example, Nepal should consider widespread adoption of NAPPI http://nappi-training.com/ ) but the point is to develop the infrastructure for training. This cuts across all discplines. MCH personnel and critical personnel may have different clinical focus, but the training system needs to not be duplicative.

Supporting rural placement for doctors  and the issue of “thrashing”

There are many issues why young doctors are reluctant to enlist in service in rural areas, and among them is the risk of harm from family members of patients who die. This is a bonafide concern, and this blog has published many entries to raise awareness of the issue. Lancet, the UK medical journal, has published a series of articles exploring the way doctors in India are coping with this as well. All new MBBS doctors in Nepal need to have training in de-escalation of anger during  patient party counseling. The standard courses taught by CCNEPal since 2011 have always addressed this issue through role play and discussion.

Browsing this blog

This blog has more than two hundred entries on topics of critical care education in Nepal and the reader is invited to look at all of them.

IMG_20150108_112956

All the props, packed up and ready to travel. CCNEPal 2016 was essentially one loooong road trip. What will we do in 2017?

Summary

CCNEPal  has trained 2,885 Nepali nurses and doctors in critical care skills since 2011 with especial attention to the Terai region. We have expertise in cultural aspects of Nepal health care and health professions pedagogy that few other outside contractors can match. We offer our expertise to those leading the process of designing Health Systems Strengthening activities. We would be honored to work alongside the successful Lead Agency for this USAID project, whoever that may be.

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