Teaching when #English is the #Second #Language for the Entire Class #ESL


Pre-emptive announcement:

This blog is directed to my videshi readers. I am pointing out the need for videshis to adapt to the culture of Nepal.  I invite comments but I will only publish if they are respectful. 

Give yourself time to click on every blue link. 

Update: I am told by multiple persons that “code switching” is what I am talking about. I confess my ignorance in not knowing what every else knew! There are ample links about code switching, and anthropologists have popularized this term. I will write an entire blog on code switching in my context,  once I digest them all. Global Health Nurses! Learn to code switch! Here is a ten-minute video from a linguist. 

Update #2 Here is a article specific to code-switching on Nepali TV. Gives good examples!

Nepal

My first trip to Nepal was in 2007 and I come here almost every summer. Since 2011 I have my own project to teach critical care skills to nurses and doctors, but I often run into other western health care people trying to teach this or that skill, or spending time here as part of their professional development. I don’t hang around with mountain climbers in Thamel or EBC.

I am fortunate to enjoy a good reputation for my sessions. Here is  a Nepali-language sample of feedback from a person who took my training:

Travel Back in Time

Seven years ago I once wrote a blog titled “Twelve Steps to Prepare for Global Health Nursing” which made the case for easy ways to learn about the culture of whichever country a nurse might think of going. I re-read it recently and it withstood the test of time. There is one area to add, though, specifically on the topic of teaching nursing in an English-speaking low income country.

Imagine yourself in a classroom with this guy as the teacher:

Now imagine that these guys are your students and this is the level of English they speak.  I have taught many of my sessions outside KTM Valley where this is the level of English possessed by much of the class.

Now imagine this is the lecture you are trying to deliver to those guys:

The American guy in the video obviously knows his stuff. The speaker is knowledgeable, speaks clearly, makes his points including nuances. Tell me honestly,  will they get it? 

The answer is obvious. 1) he talks too fast 2) he uses too many big words 3) he uses complex grammar. 4) not enough time for students to write notes 5) complicated graphics. 5) no pauses for people to process.

He is a terrific lecturer for America audiences but he would be frustrated in Nepal.

There are many Nepali people with excellent English, don’t get me wrong:

Pronunciation

English is not pronounced in Nepal the way you think it is.  Here is some info about  the way words are sounded out:

 

The language of instruction is English,” I have been reminded in about two dozen locales of Nepal, by various and sundry. This is said of Nepal (which was never conquered or colonized), but it also applies to such places as India, Nigeria, Jamaica,  Guyana, Singapore and other former colonies of Britain.

Um, no. It is not. To truly become successful you must understand the idea of hybrid English, also known as “Pidgin.”

ESL

The language of instruction in Nepal is English as a Second Language (“ESL“), not English. There are lots of Americans ( and Brits and Aussies)  who don’t know the difference.  ESL implies that the student’s grasp of English  has very specific limits. In USA these days any given nursing school will always have a subgroup of ESL students, and they often need coaching as to how to grasp “medicalese” – (when you get down to it, most medical professionals don’t speak English either!).

Because of the Medicalese issue, I learned long ago in USA to treat my entire classroom of beginner nursing students as if I was teaching them a foreign language. Think of all the  abbreviations a practicing nurse or doctor will use in daily work. I am very proud to say that my current employer ( a community college) devotes resources to the success of these students.

ESL in USA

Last spring there were some Latina students in my USA lecture class who formed a study group and made this video:

 

Back to Nepal and “Foreign Lands”

The ideal of course, is for every American volunteer abroad to speak and teach in the local language.

When learning the local language is not possible, it is very important to adapt your own language so that it mirrors the English the students speak.  Assess the level of language skill of your listeners very carefully, and reserve your most erudite English only for those at the top tier of English proficiency.  Switch your style to fit the audience.

There are people who get it, and others who keep the same speaking style they use in USA, telling themselves something like “I’ll help people more if I model my mastery of the language and elevate the English comprehension of the listeners.”

Nope. That lasts about a minute. The audience will be lost and confused. They will politely listen because after all, you are a foreigner and you have come such a long way. But if somebody asked them what you just said, they are unable to describe it.

International Conference in Kathmandu

I saw this in the ballroom of Kathmandu’s Hyatt Regency a few years back when a distinguished cardiac surgeon from USA was speaking to two hundred people about developments in mitral valve surgery. I thought it was interesting. But, most Nepalis in my vicinity sat politely, looking at FaceBook on their mobile. The conference was funded by the University in USA that sent the surgeon; they subsidized the conference registration fee for most of the listeners; but the points sailed right over the heads of the people in the chairs.

The Nepalis themselves put on better conferences organized by Nepalis for their own colleagues.

International Conference on USA East Coast

A few years back I also attended an event for Global Health Nursing in which the keynote speaker recycled a scholarly paper to present to an audience that included many academics from USA interested in Global Health, but also many nurses from outside USA. My assessment? She too, failed to read the audience. The nurses from Haiti and Africa in attendance did not quite get it. I wonder, when we send doctorally-prepared nurses abroad, do they use this level of  language? If so, are they really imparting anything of value?

Does Incrementally Erudite Scholarly Presentation lead to cognitive comprehension? 

There is need in global health nursing to use plain language for the benefit of all concerned.

In an ESL classroom, the focus is on the learner and what they comprehend, not on the teacher. It’s a spectrum I suppose, but I am proposing that we slide the marker to the right a bit…… tilt it more toward the learner.

Book culture in Nepal

Back to Nepal. the day-to-day culture here is not one that reads a lot of books. In nursing school here, people don’t study an English-language textbook by themselves. Five students gather round. The person with the best English reads it out loud, then they discuss what they just heard, in Nepali.

Here is a video I found from India, it’s a YouTube summary of a scholarly paper on this as applied in India ( a neighboring country whose language has similar origins to that of Nepal). This makes me want to read the original article! The video is 37 minute long, but it dives in to the subtleties of how English  is spoken in India and ways you can use “code talk.” The examples this person gives are in Hindi, similar in many ways to Nepali (um, Nepali is much more musical and beautiful if you ask me).

This teacher has other videos.

Singlish

Here is a video about the amalgam of Language in Singapore (Um, Not Safe for Work!) . There are surprising parallels to the way English is spoken by many in Nepal, and I know one Nepali nurse whose father was deployed with Gurkhas to Singapore, so her English is almost exactly like that of this narrator:

Online you can find dictionaries of Singlish words.  Specific to India, there is the phenomenon known as “Hobson-Jobson.” In my two books I tried to convey the way certain phrases persist among staff of Nepali mission hospitals.

Hawaii and Maine

I have always loved Pidgin languages. I lived in Maine a long time, famous for a peculiar accent,  and a vocabulary that mixes archaic words from Elizabethan England into English. I can easily speak like a native Mainer and certainly my two daughters are fluent. I also lived in Hawaii, where there is an even more distinct pidgin (you need to click on that link!) that incorporates many  phrases and grammar of Hawaiian language as well as Filipino, Japanese, and Chinese.  I am unable to imitate this at all, due to the inflection and musicality. I totally loved and respected the way this is a living language and the politics of it are fascinating to me. The musicality of an Asian language, and the grammatical differences tend to accentuate the difficulty in hearing what is being said.

Jamaica?

Listen to this one.If you can’t somehow get it, you need to tune your ear:

Some of the points about preparation in my original article reinforce this, such as spending time with the local Nepalis in USA before you depart for Kathmandu, but I think this ESL issue needs emphasis so that you have a clear goal when you are speaking with your American-based Nepali friends and preparing yourself for cultural awareness. It’s about more than just food and prayer flags.

Future blog on this subject?

there are many things I consciously do in my classroom to address this specific challenge, some I have been doing so long  I realize I take them for granted. Here is one specific example:

day Bir 2 a

the actual ten steps of defibrillation are the same whether you learn them in English or in Nepali. I always start each of my own classes by telling the group “you can be expert at resuscitation even if you speak no English whatsoever”

Bullet Points?

In a future blog I will give a list of bullet points for things to focus on when preparing for your own global health teaching experience. Until then, looking forward to your feedback.

In Summary

Add training and study of ESL principles, and even some guided practice, to your to-do list before going to teach nursing outside the boundaries of USA. Even if it is to a country where many speak English, you still need to study the language.  You will be glad you did!

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July 25th 2018 Time to stop and smell the incense in #Kathmandu


So the last teaching session for 2018 finished yesterday.

Final tally: 

sessions: 19

total certificates: 583. These are easy to quantify.

Nursing consultations: many.  Not so easy to quantify, perhaps priceless! Valerie Aikman, RN, BSN is an experienced and qualified nursing administrator and critical care manager who collaborated with administrators at every host agency. I expect that she will share her perspective in future guest blogs on this site. She brought a unique skill set to Nepal.

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Valerie Aikman, R,N, B. S was my colleague this summer. Here she is with Anupama Karnajeet, RN, B Sc who first took my course five years back. Ms. Karnajeet is a critical care specialist in her own right. Her assistance was invaluable.

Last session, back in Kathmandu

We taught 24 nurses from CIWEC hospital. This one was arranged through a former CCNEPal participant now working there, Anupama Karnajeet. CIWEC is located in Lazimpat, convenient to the big hotels and near the former royal palace.  I usually focus on hospitals in other parts of Kathmandu.

Calling Doctor Rajasthani

This training does not use PowerPoint. We do not own expensive manikins. We do not have long periods of lecture. we are hands-on and practical.

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Just a small number of costume items makes training more fun. Doctor Rajasthani is a recurring character in the drama…..

CCNEPal tends to work in Terai these days with only short periods in Kathmandu. They were having construction at the hospital so the venue was the meeting hall of the Himalayan Rescue Association nearby.

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Himalayan Rescue Association has a nice space for class size of thirty.

CIWEC

CIWEC  Hospital has an unusual history. It was originally a Canadian project,since 1982. They cater to travel medicine, about 80% of their admissions are foreign tourists. They are busiest during trekking season, spring and fall. Here is a 15 minute YouTube video (Nepali with English subtitles). The two doctors in the video also speak excellent English for those who care.

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Everest route. If you trek to Everest Base Camp and develop frostbite or HAPE, you will most likely be evacuated to CIWEC. The Tourist Association of Nepal has a system to help injured travelers.

They are famous for treatment of diarrhea, a tourist plague; CIWEC participates in research on this illness.

CIWEC gets patients with frostbite, a problem among climbers. Among the expatriate community of Kathmandu, they are the most highly recommended of any Nepali hospital.

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Poster in the OPD area. Nobody is downplaying the seriousness of diarrhea, but it’s nice to retain perspective.

Th physical plant is the closest thing to a western hospital, in the country. The mineral content of water here seems to easily corrode plumbing, for example, making faucets difficult to operate. CIWEC does not have this problem. The hospital was remarkably clean and reminded me of my own doctor’s office back in Tampa.

The rooms were nice.

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Most of the inpatient rooms at CIWEC are single-occupancy but some are double. Bright and airy.  The closest to a USA hospital room of any place.

Obviously I just spent three days with the nursing staff. They all were multilingual and spoke good English, as advertised. Many studied or worked overseas.

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The course ” Assistants”for this batch. One of the classroom management techniques I use is to delegate running the megacode drills to people who speak better Nepali than I do!

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brushing up on ecg rhythms. I teach the six step method, the international standard. the class was attentive and sked good questions.

Many previously took either BLS or ACLS and worked in critical care in other hospitals prior to joining CIWEC. The hospital is able to recruit and retain the best.

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part of the three-bed ICU.

Emergency Room at CIWEC

The ER consists of two well-equipped single-stretcher rooms.

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each ER room has’s own ambulance door and an inner door. They have a “minor Operating Theater” adjacent to the ER as well as a larger O.T upstairs. They can do endoscopy.

I wrote relatively little this summer on this blog, I was busy teaching. I expect to backtrack over the fall and fill in the gaps. This will include ideas about summer 2019.

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Monkey Business in Nepal Critical Care Training July 21st


July 22 update the trip back to Kathmandu was uneventful. The temp here is is in the 80s (f)  as opposed to 100 (f) and it is amazingly quiet at night when you don’t run the air con. For some reason my spellcheck keeps correcting it to zircon.

Numbers: eighteen sessions completed, 559 certificates distributed.

We are now in the “Shalom Annex 3” since the regular Shalom is full-up with medical students from Newfoundland. it is near Ekantakuna, a pleasant little chowk. We got groceries and put them on the pantry shelves.

We were chatting on the back porch, when we heard a noise in the kitchen. It was a monkey that snuck in through the window. He had opened the fridge and strewn about some noodles. We scared him away. the neighbors came, so did the other boarders. We learn that this guy has been patrolling the area.

Alas, no photos of the kitchen scene.

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We named our neighbor “Curious George” of course.

July 22nd, 23rd and 24th CIWEC Clinic in Kathmandu. The actual training hall will be at Himalayan Rescue Association in Lazimpat.

July 25th, to Aug 2nd – open dates. we will meet with supporters and friends in Kathmandu…  time to “stop and smell the incense” and there are many persons we wish to meet with before we leave so as to set things up for next year.

August 2nd – rendezvous with TIA for flights to USA.

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July 6th 2018 Update for CCNEPal


UPDATED July 13th

This will be brief.

we now have about two weeks remaining on this trip. We have taught seventeen sessions and given 489 certificates. We will give about a hundred more if all goes to plan.

Valerie Aikman,RN, BSN has been a wonderful addition to the CCNEPal team, offering a level of consultation on nursing issues I was not able to do in the past. I will write more about her in the future. She will most likely write some guest blogs.

Calendar:

July 15th, 16th, 17th Narayani Samadayik, Bharatpur. We will work with a very longtime colleague, Dr. Kalyan Sapkota. This will be a three-day session and include nurses from the District Hospital here.

July 18th, 19th and 20th – one last 3-day session at College of Medical Sciences. for nurses. We have truly enjoyed our collaboration with College of Medical Sciences, and we are discussing how best to work together in future.

mugling road landslide

July  21st – return by airplane back to Kathmandu Valley.  Since monsoon there are more landslides on the Mugling-Narayaghat highway. Since my bus accident a few years back I plan the travel so as to take the fewest bus trips possible. Therefore, a plane ticket. We did take one bus from Janakpur to Chitwan.

July 22nd, 23rd and 24th CIWEC Clinic in Kathmandu. The actual training hall will be at Himalayan Rescue Association in Lazimpat.

July 25th, to Aug 2nd – open dates. we will meet with supporters and friends in Kathmandu…  time to “stop and smell the incense” and there are many persons we wish to meet with before we leave so as to set things up for next year.

August 2nd – rendezvous with TIA for flights to USA.

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CCNEPal 2018 updated schedule as of June 9, 2018 “On the trail to six hundred certificates”


This is the updated itinerary for CCNEPal as of June 9 2018.

We have taught six sessions since arrival, with 179 certificates given. We will do two more three-day sessions this week in Kathmandu, at Mediciti Hospital. Mediciti has been a wonderful host and I love the staff there.

At this rate we will train about 600 nurses and doctors in Nepal this year. We already trained 3,200 in past visits.

“This is not like other training”

I get similar feedback from every group. “Nobody told us what to expect, so I thought it would be one more lecture day by a videshi using all PowerPoint and many handouts. It turns out to be very practical and hands-on.”

Anybody can teach the drugs, how to do CPR, and read an ecg.

Not everybody can teach confidence, teamwork, poise and how to think under pressure.

I lie to think we are transforming the way people look at their role in critical care, and soon I will expand this idea in another bog. Not today, though.

Next Stop

We travel to Terai June 16th, by plane to Janakpur.

June 17th,18th and 19th, then 20th, 21st and 22nd. – two 3-day sessions at Janakpur. This is also a return visit. In 2016 we worked to develop ICU staff there. I am pleased to report that JHCRC is  now offering a full range of critical care services, such as thrombolysis. We expect to focus on schools of nursing there, to ensure the supply of nurses. This will be Valerie’s introduction to the Terai.

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I asked to take a photo and the shopkeeper got a new vat of yogurt out of the fridge. the yogurt here is every bit as good as the fabled yogurt of Bhaktapur!

Travel day June 23rd. long distance bus from Janakpur to Chitwan.

June 24, 25 & 26th – College of Medical Sciences (COMS), Bharatpur.  Nursing 3rd years. Also known as “Purano.” This first session will be for nursing students. COMS is a location I visit since 2011. Because it is a major teaching facility, people trained here disperse throughout the Terai region.

June 27th, 28th and 29th – College of Medical Sciences (COMS) a second batch of nursing students.

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The College of Medical Sciences Teaching Hospital in Bharatpur operates one of the busiest Emergency Rooms in Nepal. They first hosted me in 2011.

July 1st,2nd, 3rd COMS – a batch of staff nurses.

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CMS Nursing College in Bharatpur enrolled their thirdyears in the CCNEPal 3-day class. They were really good.

July 4th, 5th, July 8th & 9th, July 10th & 11th – three 2-day sessions for Medical Officers and interns at COMS. 

July 12th, 13th and 14th – Maybe time to go to Chitwan National Park so Valerie can ride an elephant and feed a tiger. My personal favorite in that location is the river trip in a dugout canoe to observe wildlife, mainly birds.

July 15th, 16th, 17th Narayani Samaiyudak, Bharatpur.

18th, 19th and 20th? possibly another session in Bharatpur, who knows!

July 22nd through 27th – this is the only remaining week to be booked with teaching or consulting.  We can do two three-day sessions (for nurses) or three 2-day sessions(for MBBS). We have passed emails with various hospitals in Pokhara and western Terai but nothing is confirmed. If any body reading this wishes to host a session or two, please contact me at joeniemczura@gmail.com

July 28th -return to Katmandu

August 2nd – depart  Nepal for USA.

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June 9 2018 update on anatomy lab for our training course on critical care skills


The first session for this year’s series of training programs in Nepal was held at National Trauma Center, part of Bir Hospital, for a group of BN nursing students. One member of the class had previously taken the course and asked if I was still doing the anatomy lab.

I used to always make time for this and in fact, a picture of two gloved hands holding a heart serves as the profile pic for CCNEPal FaceBook page.

These days? well, no, I haven’t been including it.

Why not?

There was no good answer, so – we enlisted various class members to  go to their local fresh shop and find “en bloc heart and lung assemblies” – and we had an educational time that revealed many secrets of the heart.

I wrote about this five years ago, and here is the link: https://wp.me/p1pDBL-fp

We are now at a large Kathmandu hospital where we are training four batches of nurses with thirty people in each. We are including the lab in all four sessions of the course.  The use of this material of to advance scientific knowledge, and the goats would have been harvested anyway. In fact, the lungs would have been fed to neighbor dogs. There is a nearby fresh shop that supplies five each time, one for each group of six students.  Enough to allow each student to get a close look.

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We make a systematic tour of elements of the heart, lungs and trachea, finding such things as the pericardial sac, the valves and the coronary arteries. No matter how well the teacher can draw, there is no substitute for seeing the actual structure. Each nurse who participated will now make better physical assessments of their human patients because of the knowledge they gained.

Here is an example from YouTube that shows one way to do the dissection. https://youtu.be/XH4K4b0N_Yw I think it has the info, but I don’t lead my own labs that way – she’s is a bit passive, doing all the handling herself. It’s more fun to make the students handle it themselves and discover it for themselves.

Not wasting anything

One thing to point out: when we are finished I end up with about eight pounds of organ meat. I don’t simply throw it in the trash. I take it home and recycle it. Each set of heart & lung gets cut into small pieces. I bring it up to the roof of the Guest House for the crows to enjoy.

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I do not waste the flesh or put it in landfill. As many as three dozen crows swoop in to take morsels back to the nest for their young. There is one day per year in which crows are venerated on the Hind calendar.  This batch of crows is getting food every day for two weeks.

The crows get excited when they see me climb the spiral stairs to the top patio.

The One Mystery

So far, no group has been able to identify the structure of the heart from which True Love emanates. We will keep searching.

 

 

 

 

 

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CCNEPal itinerary for #Nepal critical care teaching summer 2018, places and dates


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At Bir Hospital school of nursing, the B Sc program is for nurses who completed PCL then have worked for two years. The focus of education there is to improve medical-surgical nursing and they are keenly interested in critical care. I was there last year and the students were excellent. The “five assistants” are shown, wearing the distinctive uniform sari of Bir.

We arrive May 17th (Joe) and 19th (Valerie) and run around like crazy getting supplies and things organized for a couple of days. Wish us luck!

The schedule is falling into place

May 20th,21st and 22nd – Bir Hospital B Sc students. These nurses have completed their PCL nursing and are going for the B.SC. degree. Bir is government-run. It is the main teaching hospital for NAMS, the National Academy of Medical Sciences, and serves as a free-of-charge resource for people from all over Nepal. Located right on the edge of Old Kathmandu. This is a return engagement for us.

May 23rd, 23th and 25th Bir Hospital Trauma Center staff nurses.

May 26th holiday and recuperation

May 27th, 28th and 29th – National Burn Center staff nurses, Kirtipur

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The “HDU” at Kirtipur is the most active critical car unit for burn victims in Nepal. This will be our second trip to teach there.

May 30th and 31st National Burn Center Kirtipur, interns and Medical Officers (2-day)

June 1st and 2nd holiday for two days – r & r

June 3rd, 4th & 5th – Meditici 3-day #1 session. This is a new facility just outside the Ring Road in Lalitpur.

June 6th, 7th and 8th – Mediciti 3-day,  #2 session.

June 9th – travel day. From Kathmandu to Janakpur. This begins the Road Trip through Terai.  Most likely we will fly there. My first trip in 2016 was memorable and epic.

June 10th,11th and 12th, then 13th, 14th and 15th. – two 3-day sessions at Janakpur. This is also a return visit. In 2016 we worked to develop ICU staff there. I am pleased to report they are offering a full range of critical care services, such as thrombolysis. We expect to focus on schools of nursing there, and we have yet to determine whether we stay an additional week. It depends on the demand for training and also whether we will add a PALS course, etc.  specific breakdown TBD ( combination of 2-day and 3-day sessions)

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I asked to take a photo and the shopkeeper got a new vat of yogurt out of the fridge. the yogurt here is every bit as good as the fabled yogurt of Bhaktapur!

Travel day June 23rd. long distance bus from Janakpur to Chitwan.

June 24, 25 & 26th – College of Medical Sciences (COMS), Bharatpur.  Nursing 3rd years. Also known as “Purano.” This first session will be for nursing students. COMS is a location I visit since 2011. Because it is a major teaching facility, people i train here disperse throughout the Terai region.

June 27th, 28th and 29th – College of Medical Sciences (COMS) a second batch of nursing students.

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The College of Medical Sciences Teaching Hospital in Bharatpur operates one of the busiest Emergency Rooms in Nepal. They first hosted me in 2011.

July 1st,2nd, 3rd COMS – a batch of staff nurses.

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CMS Nursing College in Bharatpur enrolled their thirdyears in the CCNEPal 3-day class. They were really good.

July 4th, 5th, July 8th & 9th, July 10th & 11th – three 2-day sessions for Medical Officers and interns at COMS. 

July 12th, 13th and 14th – Maybe time to go to Chitwan National Park so Valerie can ride an elephant and feed a tiger. My personal favorite in that location is the river trip in a dugout canoe to observe wildlife, mainly birds.

July 15th, 16th, 17th Narayani Samaiyudak, Bharatpur.

July 18th,19th 20th open, any session needs to be in Bharatpur.

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

July 22nd, 23rd, 24th possible Danghadi. tentative, CCNEPal has never been further west than BTWL, it’s about time don’t you think?

July 25th, 26th, 27th possible Dangadhi at Zonal Hospital.

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The “standar5d class size” is thirty. Five are asked to be “assistants” ans then five groups of five each. So, we need five sets of the flash cards! They are colorcoded. Each assistant gets a laminated list of the possible scenarios we will eventually be doing……. this system is impervious to loadshedding.

Subsequent dates and locations tentative, will be announced as they are booked.

July 28th, travel day. We will disappear from one location and re-appear as if by magic, hundreds of miles away. Here is a short video that explains how this is done:

July 29th, 30th, 31st – one last session in Kathmandu. Historically, CCNEPal has always offered a few first-come-first-served sessions in Kathmandu, and we have been reminded that this year’s schedule has not allowed room for such trainings.

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Pediatric Life Support course: we have yet to schedule these sessions, stay tuned.

one of our youngest patients

Nepal is a low income country and the profile of illnesses are not quite what you would see in USA. Read my first book, The Hospital at the End of the World, to learn more.

Return to Kathmandu the week of July 29th.

Fly out back to USA August 2nd.

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