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.

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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.

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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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CCNEPal Summer 2017 How to arrange hosting a session of the ICU training


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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.

It starts May 12th and ends July 14th

May 16th update: I leave for Terai in the morning.

My Nepal phone chip has been activated. The number is 98010 96822

To call me from USA: 011 977 98010 96822

I prefer SMS text. Do not phone or text me after 9 PM

I arrive in Kathmandu on May 12th and I’ll be in Nepal for eight weeks this time. It’s a bit shorter than last summer. The plan is to teach in Terai and western Nepal as much as I can.  As before, any medical center or school interested in hosting me is invited to contact me:

joeniemczura@gmail.com

 

How to host

I will travel to locations outside Kathmandu if the host can do the following:

  1. provide a class space suitable for the program. This  needs to be a big space. We move around a lot during this class. It needs: 1) a whiteboard (I do not use PowerPoint) 2) thirty chairs, 3) five patient beds or trolleys for the role play scenarios. 4) air con if possible. The classroom needs to be away from a patient care area. ( we make a lot of noise).

    img_20160710_144458_panorama_edit

    panoramic view of classroom space. I asked them to bring the beds, for the small group work. the space was ideal for our training and I recommended to them to keep the beds there. in this ic, the groups are working on scenario practice, a key component of all such courses.

  2. provide a roster of thirty nurses and/or doctors or MBBS students for each session of two, or three days. Nurses take a 3-day sessions and MBBS take the 2-day/ Each participant must attend all sessions of the same class to get the certificate (in other words, the three day class is a three day class – not three one-day classes). arrange for morning chiya and lunch, if there is not a cafeteria.
  3. The sessions are for PCL nurses, B SC nurses, or MBBS. I do not register ANMs in the class. It’s okay if the person is a recent graduate, but the persons need to be working in acute care or intending to work there.
  4. while at a place outside of KTM Valley, the host provides fooding and lodging. I live simply, it can be at a guest house, no need for finest hotel in town. I eat  DBT etc so I’m okay with local food. At some locations, they lodge me in a private room on cabin ward. ( they do not need to check my vital signs though!)
  5. My preferred schedule is to teach six days per week, either two three-day sessions (for nurses) or three two-day sessions (for doctors). I travel on Saturday and repeat. In summer 2016 I stayed two weeks in Pokhara, two in Bharatpur, two in Janakpur, and three in Biratnagar before returning to Kathmandu.
  6. I try to make a “circuit” of sessions, not go out-and-back from Kathmandu all the time. It’s more efficient.
  7. I supply the certificates. I keep a minimum amount of photocopy but we need about six pages per person.
  8. My Nepali is poor ( I am ashamed to admit). Strange as it may seem, that is not an insurmountable obstacle if there are some English speakers. I adapt my teaching techniques in a certain way. If a person has no English, this may not be the class for them.

Kathmandu

I’ll try to teach at least one first-come first-registered session in Kathmandu, open to nurses that are not employed by a hospital (yet) or whose hospital is not large enough to host a session on their own.

 

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#Janakpur Medical College for sale April 2017


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The ICU at JMC Teaching Hospital (city). I was there for two weeks in summer 2016 to train staff since it has recently re-opened.

Here is a story of Health Care in Terai that is not getting any national attention in Nepal, though it should.

जानकी मेडिकल कलेजका कर्मचारी आन्दोलित http://www.enayapatrika.com/2017/04/08/138097/

एक वर्षभन्दा बढी समयदेखि तलब नपाएको भन्दै जानकी मेडिकल कलेजअन्तर्गत सञ्चालित शिक्षण अस्पतालका कर्मचारी आन्दोलित भएका छन् । जनकपुरस्थित शिक्षण अस्पतालका चिकित्सक र कर्मचारी काम नै ठप्प पारी आन्दोलनमा उत्रेपछि अस्पतालका सम्पूर्ण सेवा बन्द भएका छन् । ०७० सालदेखिको सबै तलब भुक्तानी, समयभित्र मासिक तलब दिनुपर्ने, करार नवीकरण हुनुपर्ने, सञ्चय कोषको व्यवस्था गर्नुपर्ने र जेएमसिटिएचको ०६४/६५ को नियमावली कार्यान्वयन हुनुपर्नेलगायत माग गर्दै कर्मचारी आन्दोलित भएका हुन् ।समस्या समाधान गर्ने विषयमा पटक–पटक कलेज व्यवस्थापनसँग सहमति भए पनि समाधान नभएपछि आन्दोलित भएको अस्पतालमा कार्यरत सञ्जय चौधरीले बताए । यसबीचमा दुईपटक सञ्चालक फेरिए पनि समस्या समाधान नभएको उनले बताए । उनले भने, ‘व्यवस्थापन सहमति गर्छ, तर समस्याको समाधान हुँदैन ।’

कलेज बिक्रीको हल्लाले कर्मचारी त्रसित

कर्मचारी दुई महिनादेखि आन्दोलित भए पनि कलेज सञ्चालन खर्च र बैंकको ब्याज असुल नहुने भएपछि बिक्रीमा राखेको एक सञ्चालक सदस्यले बताए । कलेजको ऋण १ अर्ब १० करोड र कर्मचारीको तलब करिब २० करोड बाँकी रहेको ती सञ्चालकको भनाइ छ । यस्तै, विद्यार्थीको मेस तथा अन्य खर्चबापत करिब २० करोड उधारो रहेको तथा कर, बिजुली बिल गरी करिब डेढ अर्ब रुपैयाँ तिर्नुपर्ने अवस्था रहेको ती सञ्चालकले बताए ।

कलेजको समस्या निवारणका लागि नयाँ व्यवस्थापन पक्षले कलेज बिक्रीमा राखेपछि पुराना सेयरधनी त्रसित बनेका छन् । कलेजका पुराना सेयरधनीमध्येका बलराम गुप्ता, समीर ढुंगना र उनकी श्रीमतीले सेयरबापतको करिब २५ करोड नपाएको बताएका छन् । विद्यार्थीले कलेज सञ्चालकमाथि ठगी मुद्दा दर्ता गराउने तयारी गरेपछि ढुंगना र गुप्ताले उधारोमा कलेज बिक्री गरेका थिए । कलेजलाई धनुषाबाट सार्ने तयारी भइरहेको र एक भारतीय नागरिकसँग नयाँ व्यवस्थापनले कलेज बिक्रीबारे कुराकानी गरिरहेको कलेजका एक कर्मचारीले दाबी गरे । कलेज किन्न भारतको चेन्नईबाट एउटा समूह आए पनि पूर्वाधार नभएपछि बार्गेनिङ गरिरहेको उनले बताए । यहीबीचमा भारत झारखण्डका केही व्यवसायीले पनि कलेज किन्न स्थलगत निरीक्षण गरेको उनले बताए ।

विद्यार्थीको भविष्य अन्योलमा

दुई वर्षपछि विद्यार्थी भर्ना गर्न अनुमति पाएको कलेजमा यसपटक करिब ५० जना विद्यार्थी भर्ना भएका छन् । उनीहरूमध्ये अधिकांशले किस्ताबन्दीमा शुल्क बुझाउने सहमति गरेका छन् । बुझाइएको शुल्क सञ्चालकले भागबन्डा गरिसकेका छन् । कलेज र अस्पताल सञ्चालनका लागि दैनिक खर्चसमेतको अभाव रहेको अस्पतालले जनाएको छ । तेस्रो र चौथो वर्षका विद्यार्थीले प्राक्टिकल गर्न पाइरहेका छैनन् । सिटी अस्पताल बन्द भएपछि उनीहरू बिचल्लीमा परेका छन् । कलेजका एकजना सञ्चालकका अनुसार कलेजको आम्दानीले अहिले ‘अप्रेसनल कस्ट’समेत उठ्दैन । उनले भने, ‘मासिक एक करोड ब्याज, डेढ करोड तलब, बिजुली, इन्धनलगायतका सबै खर्च धान्न महिनाको झन्डै तीन करोड चाहिन्छ ।’ अस्पताल र कलेजमा करिब पाँच सय कर्मचारी कार्यरत छन् ।

Janaki Medical College serves one of the poorest parts of Terai. There is a history of financial difficulty at JMC, and they have been on the radar of Nepal Medical Council for a number of years, charged with various action-plans to improve services.

 

The troubles continue. The Medical College is now for sale but nobody in the region has stepped forward with the money to invest. The asking price? 15 to 18 million USD.

I spent two weeks in Janakpur in summer 2016 to train nurses and doctors in critical care skills. If the teaching hospital is closed, that means there is only one ICU in the entire region to treat critically ill patients.

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Feb 27th – CCNEPal announces NEW GoFundMe campaign for summer 2017


img_20150415_120312Summer 2017 CCNEPal will once again teach in Nepal.

Today we announced a new, scaled-down fundraising campaign to support CCNEPal’s summer 2017 activities. We are trying to raise $4,000 for a three-month trip to teach ACLS in Nepal, especially the areas outside the Kathmandu Valley.  go to: https://www.gofundme.com/nepal-mission-for-critical-care to learn more.

This is not our first trip to the rodeo

CCNEPal has a long track record of successful training. We have taught ninety sessions of the 2-day or 3-day course in critical care skills. Since 2011 when we decided to focus only on critical care, we have given 2,885 certificates. We have trained nurses and doctors in Biratnagar, Janakpur, Chitwan, Palpa, Bhairawaha, Pokhara, Dulikhel, Manthali, and of course, in all parts of Kathmandu.

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Sustainability is the goal

Our long-term commitment to Nepal has meant that we are developing a core group of people who will become teachers of this set of skills and establish a homegrown ability to pass these skills, and the attitude of critical care, to the next batch of juniors. We use a particular teaching style to empower the participants based on extensive knowledge of South Asian pedagogical style.

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the group picture. the 23rd of 24 groups for summer 2016.

Shoestring budget

The funds raised by this campaign will be used efficiently. We expect to teach 24 sessions and reach about 700 nurses and doctors. That’s roughly six US Dollars per student reached. We have very little overhead. The return on investment per student is tremendous. We are not personally saving any lives – we are teaching the Nepali doctors and nurses to save the lives. We give them the tools. This is a “force multiplier” for CCNEPal’s goals.

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Click here to contribute: http://www.gofundme.com/nepal-mission-for-critical-care

 

 

 

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CCNEPal 2017 summer plans – sign up now!


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?

This is a brief announcement.

I expect to be in Nepal once again for summer 2017. My plan is to teach more sessions of the 2-day course in Cardiac Life Support for MBBS docs and interns, as well as the 3-day course for nurses and nursing students. Please browse through back entries in this blog – there are about 240 essays on various aspects of this project. Go to the FaceBook page and browse around – you may very well know some of the 2,885 people who already took this course since 2011.

I will arrive around May 10th and return to USA around August 15th or so. The summer will mostly be a circuit trip.There are three main phases of what I expect to do:

  1. I will land in Kathmandu Valley, run around like a crazy man gathering supplies for a couple of days, then get on a bus to Terai (or somewhere).  I will settle in a location like a nomad, set up my yurt, pasture my yaks, and teach as much as I can for two weeks at a time. Similar to last year.
  2. In the middle of the summer, one of my family members may be visiting. At that time, I will take a two-week break in Kathmandu during which I will be the guide for any and all nurses or nursing faculty who wish to learn about Nepal culture, Nepal healthcare, and Nepal nursing.  During this period, I expect to focus on helping other videshis get up to speed on how they can interface with their peers, as opposed to simple sending them off to trek with toothbrushes or teach English in an orphanage. If you know of any nursing faculty for whom this might be appealing, let me know. I don’t know the dates but probably first two weeks of July (tentative).
  3. When those persons have finished their time, I will return to Terai and resume teaching. I have this dream of visiting Beni the site of my novel; also, I wish to finally go to Jumla, the mysterious locale in western Nepal, to fulfill various solemn promises made to people long ago, some of whom are now deceased.

How to Book me?

I already got one request for me to spend two weeks in Palpa, at L.M.C. where I’ve taught before (and I also had a fine time). I do not generally construct the exact schedule of teaching too much in advance because it will inevitably change at the last minute anyway and even if it does change, I can always find people interested to work with me. (I am immensely flattered every time). So – if you are a host agency, just send me an email or a FaceBook  message. I ask that the host agency pay for my lodging and fooding. I live and eat like the locals ( I admit though, Air Con is very nice when I am in Terai!)

IMG_20150315_142303_edit

Thousands of lives lost in the April 26th earthquake. Please pray for Nepal.

General Goal

Any Nepali nurse or doc reading this who wants to help teach and set up their own program in Nepal is strongly encouraged to contact me. This project is entering it’s sixth year, and we should be getting to the point where many people have taken the introductory course. For the skills I teach to be “sustainable” we need to think of ways to develop Nepali expertise in teaching and presentation as well as how to integrate into the ongoing curricula of nursing and medicine. If there are more requests than I can fulfill ( as has happened in previous years) I will prioritize the ones where the host can commit to finding people to adopt it in their own location with teachers that I train and then take over the content. This has happened in some places, but not others.

We have seen tremendous response to this project since it’s inception, and I hope 2017 can be just as good a collaboration as previous years.

 

 

 

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getting a handle on #GlobalSurgery via video links Dec 30 2016


Everything I write is based on a simple premise: If you are a medical professional from a developed country trying out #Globalhealth or #globalsurgery for the first time, you need to know as much as possible before you go. No matter how much you study, the first time is always an eye-opener. Phone me if you have questions or need advice – especially if it’s Nepal.

My belated supplement to Goats and Soda

In April 2016, Goats and Soda did a piece on a surgeon in a challenging environment.

http://www.npr.org/sections/goatsandsoda/2016/04/26/475617180/the-improvisational-surgeon-cardboard-casts-no-power-patients-galore

I thought I would look through YouTube and find some other videos that put the problem in perspective. Here they are:

 

The Birth of the G4 Alliance

 

 

The Right to  Heal

End Fistula

Aloha Medical Mission – from Hawaii – I know these guys. They are amazing. they are self-contained – bringing the whole team with them. This is one way to do it. Brad Wong, MD has also served in the capacity of being the only USA surgeon (with an all-Nepali team) on one of his trips to Nepal. I think this video below captures a lot of the team spirit:

 

My YouTube Channel

I take videos in Nepal when i am there, to show such things as how a nursing school learning lab is equipped. This is not the kind of thing destined to bring me viral fame but I did it for you. To see a playlist, go to https://www.youtube.com/playlist?list=PL05C15E3E2862A608

The TV show “ER”

There are many perspectives on offering your self to serve in a low-resource country. From the videos above, you get the idea of the need. There is a large gap between the medical care of USA and that of the developing world.

From the perspective of the person doing this, the person sitting down and making as rational a plan as possible before stepping out of their comfort zone, it’s an adventure regardless of which country you will go. And yes, the various possible options exist along a spectrum. The TV show “ER” did a sub-plot a few years back in which some of the surgeons-in-training went to a war zone in Africa.

As befits a dramatic series, the team is in over their heads, they are in a war zone, things go horribly wrong – actually this is the nightmare for the surgeons mother ( um, what she doesn’t know won’t hurt her. Tell her you are practicing classical piano every day like Albert Schweitzer did).

My own book is about a USA surgeon in Nepal and is set during the Nepal civil war.  There is a separate blog ( https://sacramentofthegoddess.wwordpress.com) for it.

To read the reviews go to: https://goo.gl/PGTW30

9781632100085-SOTG-Nepalt.indd

Many people decide to read a book only after looking at the back cover. Here’s the one for The Sacrament of the Goddess https://goo.gl/PGTW30

Please share and feel free to comment.

 

 

 

 

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Vandalism and anger at CMC Dec 2016


A pregnant woman died in Terai last week, and the family was overcome by grief. They showed it by angry protests. The doctor is always blamed, regardless of the facts. This is an issue that prevents young doctors from wanting to serve in rural areas. Here is more info. The news was sad for me:

Description

Alert: Chitwan/Dec 7, Birami ko mrityu pachhi aakroshit aafanta haru dwara Budhabar Chitwan Medical College ma todfod, 3 prahari sahit 4 ghaite.

The kin of a pregnant woman who died at Chitwan Medical College vandalised the hospital today.

Sunita Gurung, 25, of Bharatpur sub-metropolis was admitted to the hospital after she complained of labour pain. After Gurung died last Monday, her relatives have been staging protests saying that she died due to doctors’ negligence. The irate kin also damaged the glass of the hospital’s main door.

DSP Dipak Shrestha of District Police Office, Chitwan, said four persons, including three police personnel were injured when agitators pelted stones at the police when the latter reached the site to control the mob.

Soman Singh Gurung, family member of the deceased, said Binam Gurung was injured in the incident. Police have arrested five persons and kept them in custody for being involved in vandalism, informed DSP Shrestha.

The victim’s family, however, claimed that seven persons, including one woman were arrested. DSP Shrestha said five were held for vandalism and attack against police.

Soman Singh said Sunita was admitted in the hospital at 3:30am last Monday after she underwent labour pain.

He said Sunita died at 12 noon though the doctors had assured them that she would deliver the baby in two hours without surgery.

The deceased’s sister Gori accused that Sunita had died due to negligence on the part of doctors.

“The doctors had told us that she would deliver the baby naturally. But she lost her life due to the doctors’ negligence,” charged Gori.

The agitating kin have demanded action against guilty doctors. They submitted a memorandum to the CDO today seeking action against the guilty and compensation for the bereaved family.

Issuing a press statement today, the hospital said Sunita had died after she suddenly developed Eclampsia, a condition in which one or more seizures occur in a pregnant woman suffering from high blood pressure, and she died while being treated at the ICU.

The statement read that the deceased’s family members had signed an agreement paper on her treatment and they were informed about the complications that could develop later.

The hospital also condemned the vandalism and manhandling of doctors, nurses, and other staffers after the woman’s death.

https://nepalmonitor.org/reports/view/12517

For the victim and her family

My condolences to the victim and her family. We do not know the details of her illness, other than being “eclampsia.”  The hospital is probably not allowed to release details. There is a lot we don’t know.

OBS at CMC

This is not an area I interface with as a rule. I teach people about teamwork and communication which is universal, but I do not address obstetrical emergencies per se. I don’t hang around the maternity department at any of the locations I teach.

CMC

In My opinion, CMC is among the very best hospitals in Nepal. I worked with them extensively over the past five years to address the constellation of issues related to angry patient parties who vandalize or thrash hospital staff.  The reader can browse about thrity past blog entries that describe aspects of the thrashing issue.  De-escalation, building design, role of security personnel, situational awareness for doctors – it’s all there.

Thrashing

This is eerily similar to the event that caused me to work on the issue of thrashing, which took place in 2009. It was very tense and became the basis of my second book, The Sacrament of the Goddess. You can buy The Sacrament of the Goddess on Amazon, here is the URL https://goo.gl/PGTW30 and there is a blog specifically devoted to the book – https://sacramentofthegoddess.wordpress.com/

9781632100085-SOTG-Nepalt.indd

Many people decide to read a book only after looking at the back cover. Here’s the one for The Sacrament of the Goddess https://goo.gl/PGTW30

 

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