Sept 31st: The NMA hospital protest fizzles out

The hospital protest is over, and the question is whether it made any difference.

Here is the press release in Nepali from Nepal Medical Association.

deal inked

I sent out a general query as to whether it was a successful protest or not. I got one particular answer I will share. It is noteworthy because the author gave a direct opinion, something very few Nepali persons will do. I have removed the name because I am not sure he wanted to become famous.

Obviously, it has been a political agenda behind the scene. Hence, it (the agreement to end protest) is not a good thing.
Demands of the majority of the doctors across the country were:

1. Jail without bail for any abuse to the health workers on duty. (Not implemented)

2. Apologize in public by the government about what they had presented at a press conference before (doctors should be liable for compensation for any death during the treatment) (Not done)

3. Determine salary of doctors scientifically (Not done) (It costs almost 5 million Nepali currency as tuition fees for Medical graduation but the current salary of a medical graduate is 30 to 35K)

4. Relaxation of retirement age of government doctor to 65 years (now it is 60 for all govt employee; some exceptions apply) and Removal of 5% health service tax was not a demand at all but NMA was focused on these two demands only. They are not going to help any doctors. This demand is focused on particular people and private hospitals

Now, what next?
Almost all the doctors who do not benefit from point 4 above are furious with NMA. some are in the opinion of establishing a parallel organization. But, one thing we doctors do not have is unity, so it will not be easy to start a fresh movement immediately.

What do i think?
Continue your days as they were before. Be careful in selecting cases. Try not to get involved in high-risk cases. I urge all the youngsters to be a member of NMA. The election will be at 3 years from now. Select a team of youngsters. Then plan ahead.

I’m writing this from USA, not Nepal, and my reading ability in Nepali is poor. But I have followed the main issue, violence against health care workers in Nepal, closely for about ten years. This has been a problem for a long time, usually swept under the rug. This past year there seem to have been more media reports of inadvertent deaths in hospitals, sensational at times. It’s an election year (there haven’t been too many elections after all) and politicians are scrambling to respond to the media reports. The media reports are generally not complete or balanced or well-researched.

Specific background to the above

If you are not familiar with the points above, let’s go point-by-point and clarify.

1. “jail without bail” is a proposal based on a law passed in 2014 in Queensland, Australia.  During the Nepal protest, an internet meme made the rounds:



2. The proposal made by the cabinet which prompted the immediate protest was one in which the responsibility for patient deaths would be more clearly shifted onto the backs of the doctor(s) involved. It has yet to be put into effect, but it has not been withdrawn either. This is an ongoing issue. In my own opinion, there is need to upgrade systems of responding to emergencies, but there is also clearly a situation in which the victim or family are often portrayed as blameless in the events leading up to a death when in fact they hold some responsibility. When the political parties get involved in negotiating on the family’s behalf, it takes on the aspect of extortion.


Here is the infamous video from the Charikot incident a year back, in which doctors were paraded in front of a crowd:

Note how young they are. And yet, they were running the place.

Another from Charikot:

This one above, gives you the idea of how volatile the protests and threats can be. A crowd has gathered and they are angry. I’m not joking when I say that this is a threat and things can get out of hand.

Another showing the crowd at Om getting whooped up, with riot police present:

What would they be doing if the police were not present? and yet, in most regions of Nepal, the police are not quick to arrive on the scene.

Here is another  example of media coverage in Nepal:

The above deals with the death of a patient at Om Hospital. Let me emphasize that I personally have no any kind of inside knowledge of these specific incidents and my heart goes out the survivors. But I have in fact interviewed and worked with nurses and doctors when many other similar incidents have occurred. I firmly believe that this kind of publicity is not helping the goal to improve medical care. The doctors run away from emergencies when the family might act this way, when they ought to be running toward the emergency.

There is a definite need for more factfinding and an orderly process when an inadvertent death occurs.

3. “determine salary of medical doctors.” This needs more explanation especially for a USA audience. In Nepal they use the MBBS system. A MBBS graduate is a “doctor” after completing a Bachelor’s Degree, and they become a “Medical Officer” after completing a one-year internship. During their time as a Medical Officer there is no system to determine salary, with the result that many work three different jobs for low pay. They are continually scrounging for clinical work and under pressure to pay off medical college loans. This is one of the reasons so many wish to go to USA or UK.  In addition, the young MBBS doctor often gets very little continuing education and is trapped into the role of  indentured servitude, because they would need a new round of loans to enroll in the “M.D.” (i.e, master’s degree) level and finally become independent. The government sets the tuition for such graduate education but there are plenty of rumors that kickbacks are required outside the regular fee.  I eould be remiss if I did not mention the work being done by Dr, Govinda KC to keep a spotlight on the need for reform of tuition at medical colleges. For that matter, there is an active effort to prevent politicians from authorizing a zillion more medical colleges in Nepal. This too, is an important quality measure.

4.  retirement age of government doctors.  Not an issue I personally am familiar with. Somehow this got settled when the other stated goals did not resolve. Exactly how many such persons did this affect? hmmm…….

My own recommendations for future activity

  1. BLS, ACLS, PALS, etc need to be mandatory for all MBBS graduates during internship.

The CCNEPal project was started in an effort to improve the level of emergency care and critical care in Nepal.  CCNEPal got involved in teaching about situational awareness because the fear of thrashing has always been part of the reason why emergency care is a problem. We need to continue to elevate the standards of training in emergency care procedures. The young MBBS doctors throughout Nepal are the frontline of emergency care and courses like ACLS, PALS, ATLS etc need to be mandatory for all MBBS graduates. Until now, these have been limited to only those doctors going for the Master’s degree.

2. These same courses need to be required for all MBBS graduates from China, India, Bangladesh etc

There is a significant number of MBBS graduates from non-Nepali programs working in rural areas where the care is needed most. They too need this skills even though they may not have done an internship in Nepal.

3. Nurses need this training, and it should be required for all nurses in emergency room or ICU.

4. better training and organization of ghar dai and police is also needed.

I could add a few more, and I invite you to browse previous blogs on this subject.



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Sept 2017 Protest by doctors regarding Cabinet proposal in “malpractice”

“Thrashing” of doctors is a problem

Last week the Nepali cabinet proposed that doctors in Nepal be responsible for compensating the family of any person that dies under their care. The Nepal Medical Association called for a  “bandh” (work stoppage) in protest. Emergency rooms are open but other out-patient activities are curtailed. As of today, the bandh is still in effect. The cabinet will revisit their proposal when the Prime Minister returns from a diplomatic trip.

This is the latest chapter in a long-running problem also found in India, Pakistan and other Asian countries. Since 2011 I teach nurses and doctors in Nepal strategies to reduce the likelihood of getting thrashed.

You think of India as the home of Gandhi, right? Nepal is the land of Never Ending Peace And Love, isn’t it? Birthplace of Buddha?

At the heart of the issue is an ugly little aspect of South Asian culture. Here is what it is about:

If a patient dies while under a doctor’s care, the doctor is blamed. The family may assault the doctor, vandalize the hospital, and demand a large cash payment for the negligent care under threat of violence. Sometimes if the patient was associated with a political party, the local political chief will whoop up their cadre in a show of force to support the money demand. This form of mob justice happens throughout South Asia, to the point where it has it’s own euphemism “thrashing. (highlighting is mine, block quote added for emphasis).”


Thrashing is a form of frontier justice — if somebody commits a physical crime against you, you immediately convene your nearby friends with four-foot long sticks, and they join you in beating that person to a pulp.

Should doctors in Nepal carry handguns?

This is a big problem for doctors especially those serving in rural areas or in high risk specialties. In Nepal the doctors don’t want to assume this degree of personal risk. The problem is sufficiently widespread in South Asia that it has been reported by the India Correspondent of Lancet, the venerable medical journal from the U.K. and the India Medical Association proposed a bill in India’s parliament to allow doctors to carry handguns.

Political Feudalism

On another level, the local grandees of major political parties tend to get involved and will negotiate on behalf of the aggrieved party in exchange for a cut of the payout. There is a minimal malpractice system. The Nepal newspapers report on a what is now a well-publicized series of incidents in which this or that hospital gets vandalized or shut down by a mob on a rampage when there is no payout. In this blog I frequently record these incidents but they are too frequent for me to keep track of every one. The most recent seems to have been a protest at Om Hospital in Kathmandu, in which a woman died after surgery to repair a deviated nasal septum.

The above video is in Nepali. The protesters were presenting thoughtful views.

Here is another that’s a bit more raucous

I want to emphasize, I do not know the facts of the case. This particular event is added onto other recent events at the very same place, as reported in the media, and that magnifies this one. Any death of any person is tragic. Fortunately the protest after this one did not escalate into vandalism and violence.

Similar incidents have taken place at many locations, and Om Hospital is certainly not the only place!


There are many angles to the problem. One aspect is denial. As a tourist destination Nepal cultivates a certain image of happy hospitality and serenity, and this idea of thrashing does not reconcile with the image. So for a long time there has been a tendency to keep these episodes out of sight. Blame the doctor especially if they are young, but not change the system. Complicating this picture is that there is more than one level of medical training in the marketplace and there is in fact some degree of low quality medical care that qualifies as bonafide malpractice, just as we have in the USA. Also, there is a low level of medical literacy and many times the critically ill person arrives in the emergency room already dying because of delay in seeking treatment.

Life expectancy and maternal-child mortality

the life expectancy in Nepal is about 69.91 years. Maternal-Child Mortality in Nepal is high, about three times as high as that of USA despite a dramatic decrease.

This present crisis

The present brinkmanship was triggered by a proposal in Nepal’s Parliament to require that all doctors assume the cost associated with claims of malpractice. It was worded in such a way as to place 100% of the financial burden on frontline doctors. It does not address the problems of real or implied violence during the time when a resolution is being worked out. This policy if adopted, would negate the use of the judicial system to resolve these disputes which they are just starting to adopt. Here is the statement from the NMA from last week:


On their website, the Nepal Medical Association wrote:

“प्रेस विज्ञप्ति

नेपाल चिकित्सक संघ केन्द्रीय कार्यालयमा आज बसेको संघको बृहत बैठकमा उपस्थित हुनु भएका विभिन्न विशेषज्ञ समाजका अध्यक्ष तथा महासचिवहरु, अस्पताल र मेडिकल तथा डेण्टल कलेजका निर्देशक तथा संचालकहरु, संघका पूर्व अध्यक्ष, पूर्व महासचिव र संघका बरिष्ठ सदस्यहरुको भेलाले गरेको व्यापक छलफलको निर्णय बमोजिम मन्त्रीपरिषद्को मिति २०७४ आश्विन २ गते बसेको बैठकले चिकित्सकहरुलाई लक्षित गरी गरेको निर्ण…यको घोर भत्र्सना र निन्दा गर्दछ ।

आजको यस बैठकले निम्न लिखित मागहरुको सम्बोधन नभएमा यहि २०७४ आश्विन ६ गतेदेखि  लागू हुने गरी देशभरका सम्पूर्ण अस्पताल, मेडिकल तथा डेन्टल कलेज, नर्सिङहोम, क्लिनिक लगायतका सम्पूर्ण स्वास्थ्य संस्थाहरुमा आकस्मिक बाहेकका अन्य सम्पूर्ण स्वास्थ्य सेवा पूर्णरुपमा बन्द गर्ने निर्णय गरिएको छ । यसको यथोचित कार्यान्वयनका लागि संघका सम्पूर्ण शाखा कार्यालयहरु, नेपाल भरीका सम्पूर्ण स्वास्थ्यसंस्था, चिकित्सक तथा स्वास्थ्यकर्मीहरुलाई यसै विज्ञप्ती मार्फत तयारी अवस्थामा रहन समेत सूचित गरिन्छ ।

तपसीलका मागहरु

१) २०७४ आश्विन २ गते बसेको मन्त्री परिषद्को बैठकले चिकित्सकहरुलाई मात्रै लक्षित गरी कानूनी राज्यको उपहास गर्दै गरिएको विवादास्पद निर्णयलाई अबिलम्ब सार्वजनिक रुपमा फिर्ता लिनु पर्ने ।
२) स्वास्थ्यकर्मी तथा स्वास्थ्य संस्थाको सुरक्षा सम्बन्धी ऐन २०६६ र नियमावली २०६९ लाई आवश्यक परिमार्जन गरी स्वास्थ्यकर्मी तथा स्वास्थ्य संस्थामाथी हातपात गर्ने व्यक्ति वा समूहहरुलाई “Jail without Bail (बिना धरौटी जेल चलान) को प्रावधानको उक्त ऐन तथा नियमावलीमा थप गर्नु पर्ने ।
३) नेपाल चिकित्सक संघसँग नेपाल सरकारले विगतका गरेका सम्झौताहरुको अक्षरस कार्यान्वयन हुनु पर्ने ।

विगतमा झै चिकित्सक संघले उठाउँदै आएको न्यायिक सवालमा समर्थनका लागि नर्सिङ, स्वास्थ्यकर्मी, नागरिक समाज, शान्ति र लोकतन्त्रका लागि पेशागत सञ्जाल (पापड), मानव अधिकार आयोग तथा संघ संगठनहरु, पत्रकारजगत तथा सम्पूर्ण बुद्धिजीवि एवं आम जनसमुदायमा यस संघ हार्दिक अपिल गर्दछ ।

नेपाल सरकारको यस्तो गैरजिम्मेवारपूर्ण निर्णयको विरुद्धमा संघबाट गरिने विरोधका कार्यक्रमबाट आम सर्व साधारणहरुमा पर्न जाने असुुविधाप्रति यस संघ दुख व्यक्त  गर्दछ र यस्तो बाध्यात्मक परिस्थितिको जिम्मा नेपाल सरकार नै रहेको जानकारी गराइन्छ ।

डा. लोचन कार्की

They are stating the call to close hospitals in protest, and the demands are:
1. To publicly revert the decision of the cabinet
2. Jail without bail
3. To carry out all the agreements made between the NMA and the government.
CCNEPal perspective
I am on the side of the NMA in this controversy. The proposed rule serves to blame the doctors for a very complicated situation, and does nothing to move malpractice disputes into a judicial arena. That does not mean that changes from the medical side are not needed. From my experience teaching more than three thousand doctors and nurses in Nepal about this very issue, going back six years, I have some specific recommendations.
1) mandatory adoption of courses in Nepal that cover the same content as Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) (or PEARS).  All 4th year MBBS students need to be certified in this. Nepali doctors who receive their MBBS from abroad should be required to have these certifications before being licensed as a Medical Officer.
2) mandatory training of all interns and new MBBS doctors in situational awareness, counseling of patient party, and de-escalation techniques.
3) establishing a national registry of all incidents resulting in inadvertent death and thrashing or vandalism.
4) note that I agree with the “jail without bail” proposal.
5) requiring that all hospitals adopt building codes that support a controlled-access secure environment, and retrofit hospitals as needed.
6) Security personnel and local law enforcement agencies coordinate their activities.
7) Elimination of role of local political parties in negotiating settlements with local hospitals. Establishment of national fund for compensation.
8) strengthening hospital risk management systems to improve system response during sentinel events.
9) formation of a national study body to analyse trends in these incidents and share information.
Nepal is transitioning into more sophisticated medical services relying on hospitals, as opposed to the prior focus on primary care, and the educational system has not kept up with changing needs.
I encourage interested parties to browse my numerous past blogs and YouTube videos on this subject.
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Join CCNEPal summer 2018 to teach critical care skills in Nepal

Interested in using your skills in an international setting for global health?


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….

……. but don’t have any contacts or  know where to start?

You are invited to contact CCNEPal and see if we are a fit for you for summer 2018.

We are looking for American RNs or MDs with acute care background who can help teach critical care skills to nurses and doctors in Nepal.

Time commitment: at least one month summer 2018.

budget: all expenses are borne by the participant. These typically include airfare $1500; fooding and lodging while in country ( $400 per month). tourist incidentals.

Locations: we expect to spend a bit of time in Kathmandu, the capital city, at the beginning and I will be happy to show you around. We spend time teaching in Kathmandu, but also in the Terai, the southern plains. This is not a picturesque experience distributing toothbrushes in some Sherpa Village in the Himalaya.  If the location is not populous enough to support a medical college and teaching hospital, we don’t go there. Read past blogs to get an idea of where we go within Nepal.

That’s it. We will help arrange things, but we don’t charge a fee to cover some mysterious and unspecified administrative costs. CCNEPal is a shoestring operation, we expect each participant to provide their own health insurance and incidentals.

What we are looking for:

Nurses and doctors with a open mind, a sense of humor, and the willingness to work hard. This is not a party experience in any way, and I need to say upfront that if you need to have alcohol to get through the day, this is not for you. (um, caffeine is another matter. I know every source of “Organic Coffee” in every city I have visited). (instant coffee is an abomination).

What it is not:

It’s not for new graduates who do not have a solid core of acute care experience. The students can tell whether you know what you are talking about.

It’s not a sightseeing trip or party opportunity. You don’t have to work six days a week like I do (and like the Nepalis do) but there will be a full schedule of teaching in your topic arranged by our partners with full classrooms. In 2017 I taught 365 people in six weeks. you do the math.

It’s not a wander-in wander-out experience for international vagabonds with a nursing degree who wish to add Nepal to their bucket list of countries. You would need to submit a CV, letter of interest, and some references in addition to engaging in country-specific preparation.


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!)

It’s not a stay at a nice hotel with a pool. We might occasionally splurge but we mostly stay in the kind of lodging the Nepali people would favor, and we eat the local food. Don’t come if you don’t like rice.

Content and approach

We use specific teaching methods to offer a two- or three-day course in critical care skills loosely based on the AHA ACLS class (though it is emphatically NOT associated with AHA nor does it lead to a USA ACLS card). So, first and foremost we are looking for nurses who are willing to study our pedagogical approach to ACLS-type training, and teach the workshop. We don’t use PowerPoint, we don’t distribute mountains of handouts, and we don’t rely solely on lecture. We are highly practical and interactive.

We have had many inquiries to teach other courses. First, some kind of one-day workshop on nurse’s responsibilities for the mechanically ventilated patient; and second, a course in recognizing pediatric emergencies.


If you are certified to teach these, we would especially like to hear from you. There is tremendous need for these two specific courses. Similarly, ABLS (Advanced Burn Life Support).

American Heart Association

As stated above, what I teach is consistent with the latest standards of the American Heart Association, but for a long list of reasons, this is not the “official” course. Having said that, if you are qualified to teach the official course, I can forward your name to the one-and-only AHA International Training Center in Nepal and you can plan to teach with them.



Dal-bhaat deluxe. Rice with lentil soup is the mainstay of Nepali diet.

Nepal is not an easy country for your first international experience, and Kathmandu is not an easy first international city, if you have never travelled.  Study and preparation is needed and it is important to begin months in advance. You will not be “parachuting in” – you would be working with local contacts in the health professions education sector with whom I have had working relationships for more than five years (in most cases).

About Language (and culture)

the main language of instruction in medicine and nursing in Nepal is English. However, there are many cultural nuances important to Nepal and it is helpful to study those. Even to know a little Nepali before you go, is a good idea.

This experience is ideal for a graduate student with the time to prepare. Browse through this site and related links, then give me a call.



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Report of Summer 2017 CCNEPal sessions in Nepal


the first Norvic “batch”included 47 people, more than usual. I had wonderful support from Kavitha Ma’am (the Matron) and Mrs. Mahima Khoju Kunwar, of the Quality department.

Packing up for a long flight

This is a quick summary of activities for summer 2017. The trip this year would not have been viable without the support of a GoFundMe campaign, to which thirteen people contributed. The campaign allowed me to buy the round trip ticket.

We were here for five weeks and taught 13 sessions  to nurses and MBBS docs, in addition to two one-day classes focusing on BLS for BDS students. To be honest, there are many Nepali professionals qualified and capable to teach BLS and it was not an effective use of my time. I don’t plan to do BLS as a standalone, again.

We taught 77 nurses at Lumbini Medical College in Palpa.


Morning tea and biscuits is oh-so-civilized. I love the collegiality imparted by this small ritual. (At Lumbini Medical College).

fifty nurses at Chitwan Medical College, Bharatpur

thirtyeight nurses and MBBS (combined class) at Charak Memorial Hospital in Pokhara;

twentyseven MBBS (intern-level) at College of Medical Sciences, Bharatpur;


teamwork teamwork teamwork. The core of the training is smallgroup work to develop the ability to think on your feet during a crisis.

eightytwo MBBS (intern-level) at Chitwan Medical College in Bharatpur

One Hundred and six nurses at Norvic Hospital, Thapathali Kathmandu; and

twentyone Medical Officers at Norvic.


The total seems to be 364 participants.


r screen that they are looking at a monitor screen hooked up to our Pinnacle tech AT-35. It is an invaluable tool. I left it with my colleagues at Norvic while I am away.

The Original plan was to stay until July 14th, but family concerns arose in USA and I needed to change departure dates.

When I return to USA I will focus on my job as a nursing faculty member, then starting in fall 2017 I will think about next steps for 2018. I wish to build on what I have done to create nationwide network of critical care educators. I think there is need for a nursing-focused course on mechanical ventilation as well as Pediatric Emergencies.



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Any USA acute care pediatric nurses out there? plan now for summer 2018 in Nepal!

You are now reading the blog to accompany a project that trains Nepali nurses and doctors in critical care skills using a 2- or 3-day course based on the American Advanced Cardiac Life Support (ACLS) course. ( let me be clear: we are not the “official” course). My summer trip for 2017 is a bit shorter than usual, but we still managed to train about 350 nurses and doctors in 13 sessions ( actually, session #13 has not finished quite yet) and BLS to 40 dental students (I don’t usually teach BLS as a standalone course, but that is another story).


I teach a lot of basic skills used in critical care, including ecg. The emphasis is on applying, not just listening to lecture. we use Scenario-based simulation approach” – very active.

Future Plans

I plan to return to Nepal in 2018, and I’m thinking about what the goals would be. To some degree we are still educating people as to what ACLS is and why it is needed. We are making progress on that front, and in the planning for summer 2017 we received many more requests to partner with host sites than we could possibly fulfill.

Building Community

We’re still working to develop more Nepali professionals with the expertise and confidence to lead this course. To truly be an independent teacher of this material requires a lot of experience and confidence, more than you would be able to develop in just a weekend-long “train-the-trainer” course. There needs to be a support system to go along with it, something we take for granted in USA. A sense of community and shared purpose built around the idea that we can prevent excess deaths with better emergency response in this specific area. The people who need the training are the young nurses and docs at the bedside in off hours, and though the “seniors” need to understand it, we have to agree that the “seniors” are not really the ones who need it the most.

Picture 443

Most Americans have a vision of Nepal as a set of quaint villages. It’s true that much of the country is rural, but this project goes mainly to cities large enough to support a medical college and teaching hospitals.


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.

One theme to emerge this year was the specific need for a parallel course in pediatric emergencies. This was requested from a variety of contacts. In USA there are several such courses, the best known being “PALS” – Pediatric Advanced Life Support. So – why not?

I do not believe that PALS should be adopted widely in Nepal lock-stock-and-barrel any more than I believe that the USA ACLS course is appropriate for Nepal. First and foremost, the USA course requires that all sessions and discussions be conducted in English-only, a requirement that is simply ridiculous especially in rural Nepal. Also, the pedagogical framework of the South Asian educational system in which Nepali nurses and doctors are immersed is a consideration. These courses are at their best when they focus on practical hands-on psychomotor skills, and effective training needs to be designed with this in mind.


Having said that, I am interested to find some people with USA acute care pediatric experience who are PALS-I (or PEARS-I, another similar course) who would be interested to come to Nepal in 2018 and teach it. Any takers?

Terms and conditions

the deal would be:

You would pay your own airfare.

You would need to commit to a month here. You would need to study the culture beforehand. No helicoptering in and out.

You would need to agree to use materials and methods appropriate to the audience. No PowerPoint, no long lectures. A good place to start exploring the approach would be the any of the sites that describes “Low Dose High Frequency” (LDHF) training. There are many, just Google the term.

You need to decide in fall 2017 whether you want to do this, because there is a lot to learn before you go the first time.

I should add that I have a friendly relationship with the Center for Medical Simulation here in Kathmandu. They are Nepal’s one-and-only American Heart Association Official International Training Center. If you want to start by teaching the American PALS course as is with no adaptations to Nepal, I am certain they would be thrilled to collaborate with you.

CCNEPal is a grassroots shoestring training operation, and we are looking for like-minded persons who wish to join us as we teach and train. Feel free to browse this site and the related links ( see the column at right). For more info send an email to

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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

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.


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

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

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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