20 million people...one cancer hospital...the space for hope

This week we embarked on expanding our services at the INP to incorporate cancer care. Partnering with Can Tho Oncology Hospital in Vietnam and building on our Cambodian relationships, our INP Oncology team, Allie Cauvel, Aliza Cutter, and Katie Tarabochia, have started the invaluable processes of completing our needs assessments. Even within each institution we find the barriers to care and the nursing training needs to vary widely. Can Tho Oncology hospital services over 20 million people. At times, these nurses are caring for three patients in a bed and see ratios of over 1 nurse to 40 patients. As is necessary the families of these patients also stay in the hospital to provide some of the fundamental care needed to keep patients healthy and safe. With families sleeping under beds, outside in the lawn, and next to patients, the environment for nurses to work in becomes challenging.

However, no matter the obstacles to safe care we see, we never cease to find remarkable and resilient nurses practicing to the highest standard of care they can. Hand charting for forty patients, administering medications, or trying to triage patient needs, these nurses work hard to care for their patients. We have witnessed innovation and creativity that is unseen in high resourced settings leaving us inspired and hopeful that by empowering our partners and facilitating them to do their best, we can make a difference.

As Aliza reflected this week, “Nursing is so so many things. It is hard and exhausting but also incredibly fulfilling and rewarding. These last few days with the nurses from Can Tho Oncology Hospital have shown me that it doesn’t matter where you are, what language you speak, or how old you are. We are all in this work together.” we feel that bond that only nurses, caring for human life, can share.

Please enjoy our INP Oncology team’s journey as they work along side our partners to improve Cancer Care and nursing capacity.

On the road again...

We are thrilled to start another wonderful year working with our partners at Calmette Hospital and Khmer Soviet Friendship Hospital. Alli and Sarah kick started our mechanical ventilator curriculum with a two week visit working with our Local Nurse Champions. After finishing our pre-evaluation with surveys and exams, they didn't waste a moment, reviewing pulmonary disease and respiratory failure. Beyond the transfer of knowledge and the improvements we see in clinical practice, the most powerful change we find is the blossoming of friendships between our teams and through these professional relationships, the birth of Cambodian Nurse leaders. We at the INP believe that it is not a unique set of knowledge or skill that we share, but it is the role modeling of autonomous nursing that we exude. Yes you must have the training and knowledge to successfully accomplish this but maybe more importantly you must have the confidence. Through these past two weeks we have seen the transformation in how the nurses partner with Alli and Sarah and later with Cathleen and Ariel to improve their practice. Stay tuned for more and enjoy the show...

Educate. Empower. Improve.

Kate Cioffi and Marites Bautista, two ICU nurses from the University of Washington Medical Center, spent two wonderful weeks helping teach ACLS, BLS, and the patient assessment to our partner nurses at Calmette Hospital and Khmer-Soviet Friendship Hospital.  No trip would be complete with out singing, dancing, classes, patient assessments, certificates, and dinner parties! We hope you enjoy their journey as much as we did. 

This is My Story, These are My Moments

The hot, thick, air was such a familiar feeling. It might have been two years since the last visit, but like clock work my skin felt sticky and the tips of my hair started to curl. I quickly recognized the reflection of that white, American nurse, with her pack on and army green linen pants looking back at me through the airport arrival glass wall. No longer surrounded by the comforts of her own language or culture she ironically looks right at home, moments away from long hours teaching nurses, observing clinical care, meeting with hospital leadership, learning new practices, implementing quality improvement projects, and loving every minute of it.

I quickly raced to the customs desk. Like a professional Cambodian visitor, I waited for my passport to be held up and some unrecognizable version of my name yelled. I breezed through the customs process, found my bag, and jumped into the car with my Cambodian colleague, Moniroth Sopheak. In addition to my visit, Moniroth was returning after a month of visiting Seattle Washington for an INP nurse exchange. Squeezed between his Mom, Dad, Sister, and brother-in-law, we enjoyed what appeared to be a game of charades with full body language, some Khmer, some English, and a lot of laughs. 

After several stops to pick up lunch, fruit, more fruit, meet family members, and drop off family members, we arrived at his home for a welcoming lunch. Holding my coconut with sleep deprived eyes, I witnessed the beautiful homecoming of a son to his mother and father; the exciting chatter as sisters moving around the boiling pots of whole chickens, rice, and soups, preparing a meal with love.

There is something that only this kind of work can bring a person. When common language and culture can not be shared, these interactions offers an opportunity to unearth a deeper human connection. As nurses we are blessed and cursed to carry these human moments with us, our patient's stories. But it is also this common thread that bonds nurses closer together, no matter the country. This is my story. These are my moments. Each day filled with joys, hopes, sadness, discouragement, frustrations, pride, honor, and above all, human connection. This world would be a better place if we all opened ourselves to such a journey. 

Cambodian Reflections: An ER Nurse's Adventure

Within a month of being selected to go to Cambodia, my bags were packed, I gave big hugs to my family and was quickly off to Cambodia. First stop, Siem Reap (the “must visit” destination of Cambodia). The ruins and temples of this region were the inspirational settings for Indiana Jones Temple of Doom and Laura Croft’s Tomb Raider… Majestic. Beautiful. Tropical. Breathtaking. After a quick day of exploration and bringing in the Khmer New Year (a water-soaked, fun, chaotic, music-filled night), I headed to Phnom Penh – the capital of Cambodia.

First impression: concrete jungle replaces ancient jungle. Phnom Penh is a world of cement, with their roads teaming with motos (small motorcycles), tuk-tuks (two-bench transportation), cars, trucks and pedestrians. Despite the traffic chaos & crowding, the people love to smile, laugh and are laid back.

My partner Sumi working with our Calmette Local Nurse Champion partners for some bedside education. Bringing Sepsis and the patient assessment into clinical practice!

My partner Sumi working with our Calmette Local Nurse Champion partners for some bedside education. Bringing Sepsis and the patient assessment into clinical practice!

Our (myself, ICU nurse Sumi and doctor at large Cora) mission included visits to two hospitals (Calmette and Khmer Soviet Friendship Hospital (KSFH)). The very first day, Cora and I taught a dozen ‘Local Nurse Champions’ and 120+ ICU and ER nurses how to do head-to-toe assessments. Throughout the two weeks we performed Quality Improvement checks by checking off nurses as they did assessments on patients. Besides the head-to-toe assessments, I am also proud of the much-need assessment sheet Sumi created for the nurses to document their findings. Additionally, it was exhilarating to see the ER nurses realize the difference and necessity of focused assessments for new patients versus when to do head-to-toe assessments. (One of the sad realities I learned about Cambodia healthcare is that ICU patients who cannot afford to pay are placed in the corner of the ER for staff to care for them “when they can.”)

Working with over 120+ ICU and ER nurses to teach the head to tow patient assessment. Phase One in Calmette Hospitals's very first Quality Improvement Project organized and lead by the INP Local Nurse Champions.

Working with over 120+ ICU and ER nurses to teach the head to tow patient assessment. Phase One in Calmette Hospitals's very first Quality Improvement Project organized and lead by the INP Local Nurse Champions.

The nurses who attended the Phase One Education Day: Learning the Patient Assessment.

The nurses who attended the Phase One Education Day: Learning the Patient Assessment.

Additionally, while Cora taught the doctors how to treat and recognize sepsis, Sumi and I taught the nurses what to anticipate for early sepsis treatment, sepsis management, and how to advocate for patients and communicate with the doctors (i.e. SBAR). At the end of our mission, we combined the physicians & nurses for a fun day of simulation at both KSFH and Calmette to demonstrate a sepsis scenario.

Highlights of the trip that went beyond the medical mission included being invited to the country to visit the family home of one of the hospital coordinators and to meet his kids. We also visited the S21 Tuol Sleng Genocide Museum, where the depressing and recent history of Cambodia was well depicted and remembered.


A few observations: 1) Nurses in both hospitals have unexpectedly fantastic skills – starting IVs, making due with supplies and equipment (who knew and NG tube would work to gravity!), intubating patients and being positive throughout their extremely high acuity and chaotic days. However, it is their critical-thinking skills that need continued growth. 2) Helmets and traffic rules are suggestions only. I literally feared for my life as I took a public van to the coast along their two lane highway. Sadly, there are dozens of mostly young patients who are intubated due to head trauma. 3) I loved that at this time of year, Phnom Penh was actually hotter and more humid than my home town of New Orleans. 4) Medical missions, like volunteering, are similar to hikes for me: it sounds like an awesome idea before I go; I wonder “what the heck I was thinking” in the middle of it; also, in the middle of the journey, I find ‘miraculous moments’ that make it all worthwhile; and afterwards, I am oh so glad I did it.

Our team with KSFH nurse leaders, Pak Sopheak and Vuth, our INP Cambodian Coordinator. 

Our team with KSFH nurse leaders, Pak Sopheak and Vuth, our INP Cambodian Coordinator. 

Our Local Nurse Champions from KSFH with me, Sumi, and Cora after our Sepsis simulation training. 

Our Local Nurse Champions from KSFH with me, Sumi, and Cora after our Sepsis simulation training. 

Building relationships and sharing nursing practice: an adventure in photos

Another two of our INP fellows, Megan Boone and Julie Schwartz, completed two weeks abroad in Phnom Penh, Cambodia working along side our Local Nurse Champions (LNCs) at Calmette Hospital and Khmer Soviet Friendship Hospital. During their time Megan and Julie engaged with our LNCs through classroom education and bedside education to learn about nursing in Cambodia and share their own nursing practices. Beyond the knowledge shared, Megan and Julie continued to build relationships with our partner nurses, impacting the nursing profession globally. Please enjoy a unique window into their experience...

The Power of Partnerships

I was welcomed into the ICU RN community...I witnessed the LNCs taking leadership rolls in education, in the classroom, and at the bedside.
— Jackie Duerr

In my international travels through developing nations I have witnessed devastating healthcare disparity. The abundance of the US healthcare system made me want to use my resources to engage in more of the global healthcare community. But I wanted to participate in a way that would empower my international colleagues and facilitate local ownership.

In April I was provided with an amazing opportunity to travel to Cambodia with the International Nursing Program (INP). Founded by UWMC ICU RN Lia Golden, the program works to partner nurses from UWMC with nurses at Calmette Hospital and Khmer Soviet Friendship Hospital, two hospitals in Phnom Penh, Cambodia. The aim of the program is to use partnerships to implement nursing education and bedside training. The program focuses on an intense education program for a smaller select group of nurses, Local Nurse Champions (LNCs), identified by their management as unit leaders. These nurses attend weekly classes and then participate in bedside precepting with the INP Cambodian coordinator.  The intent is that the LNCs will then be empowered to educate their colleagues. Through this opportunity, I participated both in teaching classes to the LNCs and facilitating them precepting their colleagues. At the bedside, I partook in and witnessed the LNCs teaching their staff the topics that the INP nurses had previously taught them. 

During my time in Cambodia, I developed a sense of comradery with the LNCs. Through my presence in the classroom and at the bedside, I was welcomed into the ICU RN community.  After a week of working together in their ICUs, the LNCs organized a dinner to share their Khmer heritage through food.  The nurses made sure to get the night off for the gathering. And they even insisted on paying, stating that they wanted to give us an authentic Khmer food experience. It was such a unique experience. The LNCs were so welcoming and eager to be a part of the learning partnership that the INP provides. In my short two weeks there, I was able to see improvement in nursing care at the bedside and witnessed the LNCs taking leadership rolls in education, in the classroom, and at the bedside. 

I am grateful for the opportunity to be a part of the INP and to have been able to travel to Cambodia and witness first hand a global partnership in the making. By taking part in precepting the Cambodian nurses, I gained knowledge for my own nursing practice and improved upon my communication skills. I also expanded an even deeper understanding of how resource rich the US medical system is comparatively. I hope to be able to go back to Cambodia to continue my professional development and foster the relationships I made with the LNCs. 

Two INPist Photo Journey Through Phnom Penh, Cambodia

Jackie Duerr and Genna Doll are two remarkable young nurses. Both working in the ICUs at University of Washington Medical Center, Jackie and Genna were passionate about getting involved with the INP. Their experience in precepting new graduates and clinical bedside nursing made them perfect candidates for our Fellowship program. Now after many hours of preparation, Jackie and Genna are sharing their incredible adventure working with our Local Nurse Champions in Phnom Penh, Cambodia. Sit back, relax, and enjoy the ride...


Pinky Shresta’s Personal Account of April 25th Earthquake in Nepal Interviewed and Edited by Rachael Collord

The 2015 earthquake in Nepal was a tragedy felt in all our hearts around the world.  Beyond the incredible lives lost and over 8 million people directly affected, it had a devastating impact on one of the poorest countries in Southeast Asia. The earthquakes aftermath on the economy and healthcare system will take many decades and many helping hands to overcome.

Surviving the Nepali earthquake herself, our Nepali Coordinator and INPist Rachel Collord, spent the next several weeks helping to pick up the pieces and supporting her Nepali colleagues.  During this time Rachael had the opportunity to interview her dear friend Pinky Shresta, one of the brave survivors and healthcare providers on site during April's earthquake.  Below is a first hand account of Pinky’s moving story.

#Rachel: Think of the day of the earthquake, April 25th.

#Pinky: The 25th of April was my second day of duty at Dhulikhel Hospital. I was posted to the ICU for the morning shift from 7 am to 2 pm. Faced with a brand new job immediately out of nursing school, new staff, new surroundings, I was feeling perhaps a bit overwhelmed, excited, curious, and nervous.

Dhulikhel hospital currently has a five bed ICU, and most of the time all the beds are occupied. Nearing the time of the earthquake, which was at 11:56 am, my colleagues and I had just finished our morning patient care and medical team rounds. Five ICU nurses were there for the shift. I was at the far end of the ICU, observing the chart of one of my patients. Suddenly the floor started shaking, followed by a horrible, deafening, thunderous sound from the shaking earth and building.

My voice was stuck into my throat. I was so scared. Patients in their bed, except the 2nd bed, were unconscious.   He was murmuring that the earth shaking would destroy everything and I could tell he was very scared as well. I looked around and could see only one nurse standing over the bedside. I stumbled to the nursing station and saw the other nurses were hiding underneath the nurses station. I could hear the sound of all the equipment in the ICU, the metal stands clanging as they shook. The only thing I could do was stand still and wait to die.

I heard my heartbeat pounding fast and echo in my ears. Sincerely, nothing was running into my mind. The only thought in my head was that the building would collapse and we would all die. Thoughts of my family finally came to me, I felt helpless not being at my home to help my parents, my grandmother, and my brother. Then finally, the most depressive thought, “If we run, what about the patients?” Finally, after what seemed like an eternity, the shaking subsided. I tried to reach my family but all the networks were unavailable. After awhile, we got permission from hospital management to evacuate the ICU.  Fortunately, none were on a ventilator but some of them were still in critical condition being an ICU patient. There is an open area just near the ICU. We didn’t waste a minute shifting the five patients in their beds and corresponding needed equipment such as oxygen cylinders, SpO2 monitors, portable suction, and vital sign monitors. The situation started to seem chaotic although every patient and staff member was evacuated successfully.

We did have some difficulty getting some of the beds through the corridors because of the aftershocks, which made us more panicked. The only thing going through everyone’s mind was getting out of the building safely. Phew! Once we were all outside, I felt a collective sigh of relief; I released all the tension from my body with a big deep breath as I realized I had been holding my breath and my muscles were tense. We then started frequently monitoring our patient’s vital signs and attending to their needs. We finally were able to check in with other wards and departments of the hospital but since we were in a separate area we didn’t need to triage incoming patients but just focus on close monitoring of our ICU patients.

#Rachel: What happened after the earthquake? How did you feel? What was your role that day as an ICU nurse?

#Pinky: Each ward of the hospital was evacuated, and all the patients were brought outside of the hospital. We stayed busy monitoring our ICU patients. After a few minutes; the head sister from the ER shouted for help. She said that the ER was overflowing with earthquake victims and they were having difficulty keeping up with flow of patients streaming in.

I had not imagined an earthquake could be that disastrous. When we went to the ER to help and I could not believe the scene before my eyes. The ER, which now temporarily resided at the front entrance to the hospital was filled with victims all over the ground. There was a huge crowd of victims, hospital staff, student volunteers, army personnel, and many more. It was like watching a disastrous type movie, an apocalypse in real life.

I was frozen in place. I could see splashes of blood on the ground. I could hear loud cries of victims and the sirens of ambulances. All the health professionals were actively involved in triage and providing first aid to victims. Suddenly I woke up to the reality. To manage the overwhelming need of first aid, severely injured victims were grouped to a red-zone with a red tag. These very critically injured victims were unconscious due to head injury, spinal injury, multiple rib fractures with dyspnea, bleeding emergency, etc. They were eventually shifted to the operating room and some were referred to other centers.  Orange zone patients required bandaging to wounds, open fractures, and splints to various limbs that were crushed by houses, rocks, and other debris. Green zone patients were fairly stable; those who had already had a cast applied and needed only follow up or had gotten first aid treatment and needed minimal monitoring. I floated between the orange and green zones as needs arose.

Throughout the day I continued to hear victims crying and expressing pain, some had their family with them, but others had lost their family in the earthquake and were lone survivors. I remember one young girl carrying a baby sister and she was crying and saying, “‘we were watching TV and suddenly the earth starting shaking, my other two sisters were sleeping upstairs, I called out to them but I could only run with my younger sister after the ceiling started to fall down. My sisters were still in there but I could not do anything.” She had injured her hand and her younger sister, who she was holding, was bleeding from her leg.

My eyes were full of tears and I began to feel choked, like I could not breathe because I was thinking of my family and my home. It was about 5 pm when I did hear one sister talking on the phone, I asked if I could call my family and thankfully she let me call home. I was so relieved to hear that my family was safe!

All night long we were busy managing the earthquake victims. The grounds in front of the ER and outpatient department (OPD) were completely occupied by victims and families. We managed to catch up with the flow of patients around midnight. We tried to keep an eye on everyone; however, it was a bit chaotic and busy. So many quakes occurred after that, but later I realized that we didn’t get time to fear for each quake or the next one. Finally, it had been about 24 hours since the earthquake happened and I had not rested and was missing my family. I finally got permission to return home.  When I saw my family, I breathed a sigh of relief seeing each of them, face to face, and alive.

#Rachel:  Can you tell me about the second earthquake?

#Pinky: It was May 12th , which is international nurse’s day. There is usually a grand ceremony on the occasion of international nurse’s day in Dhulikhel Hospital as well as the graduation ceremony of our nursing school. Despite the disastrous quake, our hospital managed to organize a small event to celebrate the day.

As my shift was about to end, I was transporting a monitor from the OR to the ICU. It was 12:50 pm. I was in the corridor when there was a horrible jerk and a wheeled machine started rolling to and fro. Again, I started to hear people shout out so loud “vuichaalo” which means earthquake. Maybe I was desensitized due to lots of aftershocks. I didn’t think of running but instead I was observing the walls, how they were shaking, and also feeling the floor and how it was bouncing us upward. Everyone was screaming. It did stop after a while. I walked into the ICU and saw my fellow nurses standing at the nurses’ station. Those fearful eyes and shivering legs, it seemed very scary now happening all over again.

Everyone at the hospital was trying to get out of the hospital but an American doctor and the nurse Matthew entered the ICU and consoled us and assured us they would stay and help. Although the situation was very chaotic, it somehow eased our threatened hearts.

Again after a few minutes, the floor bounced me.  It was like the floor was coming up to hit against us. There was a young girl just 19 years old in the second bed. She seemed very afraid and had rapid breathing. I took her hand and hiding my fear I told her there is nothing to worry upon. Again my mind moved immediately to my family, and I tried to reach them by calling. My home is in Dolakha. The epicenter of the May 12th earthquake was Dolakha and was 7.4 on the richter.

Although Dolakha was not affected in the first quake, in this second quake even new concrete houses were reduced to rubble and most houses were leaning on one side and were completely uninhabitable. I could not think of anything except my dad. Finally I was able to hear his voice on the phone, fortunately he was in a field during the quake. I did breathe a deep sigh of relief after hearing the voice of my dad and family.

Again the disaster protocol was activated, but this time we tried to make it a bit more organized than last time since we had done this before. We used the big entryway in front of the hospital gate to receive victims, provide first aid, and then after stabilization, shift to green zone. We were fully prepared. Everyone was assigned a specific task, we were very prepared this time. By the grace of god, the victims were very few this time.

The big earthquakes of 2015, April 25 and May 12, and many shocks.  An uncountable number shook everyone and left our country devastated. It was an unforgettable quake for all people, either national or international, child or old, rich or poor, for anyone being in Nepal at that time. 

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Our INPist...

The foundation of our quest is built around our nurses both at home and abroad. It is our nurses that enable us to educate, to empower, and to improve health for our patients.  Their commitment as an INPist is why we exist.  Here is a space to share their stories.  

Buckle your seat belts...our first nurse's story is coming soon...