Initiation into the tribe of Critical Care Nurses starts – now…..

Hey, check out the Joe Niemczura channel on YouTube!

Thursday I made just a small entry into the blog, a sort of tease I suppose – brief.

What’s the ideal length of these posts anyway? My former clinical students used to say I was a bit wordy at times. (Can’t possibly be true…). I think two thousand words is about right.

The Day After
I spent Thursday morning on the laptop reorganizing the ruffled pile of registration papers I jammed into my jhola at 5 PM. Getting the ‘final’ course roster into shape, cross checking the hundred or so pieces of paper and reorganizing to develop a final list to guide me as we go along. At noon Wednesday, I’d given Ujjwal a grapefruit-sized ball of crumpled thousand-rupee notes, just dumped them on his desk, and I am pleased to report that the amount of fee collected (154,000 nrs) matches my record of how many paid. I’d insisted that the course start at 0800 instead of 0900, and I requested people get there early to expedite things, but it had still been a rush. For each person who paid, I was to give a handwritten receipt and also note the fee collection in two other places; I sped this up by pre-writing the receipts the night before so all that was needed was to scribble the name.

Difficult to admit but….

This level of organization would probably stun my UH colleagues….. I am fully capable of it when pressed.

The planning helped, and we started by 0815. Ten of the people on the waiting list came, anxiously awaiting admission, and we had enough unclaimed seats to allow them in. Final number: 75.

FaceBook publicity

I don’t think the class would have been remotely so well-attended without the “event page” I created for it on FaceBook (FB) last February. But there was still a lot of last-minute word-of-mouth that got people into the room. Seventy five nurses were seated in the plastic chairs when all was said and done, and I am quite happy with that number, it’s plenty.

Classroom Management

Part of my usual planning is to attend to the way in which the class experience creates a sense of community, and we did some organizing along those lines. They broke up into eleven official subgroups of six to ten members. I took photos of class members which will go on the FB site for the page – got about half to go. There is a new FB page just for the course and I will post class announcements there as this gets going. They each shared mobile numbers.

For next week I bought some name badges and we’ll use those from now on in class. They’ll write their name in Nepali of course, and I know I can create a good vibe when I address all seventy five people by name, reading the devanagari.

The class divided into subgroups on the basis of residential geography. Ten are from Bhaktapur for example, and most of these work at “B and B Hospital”. Another group is from Boudha, and so on.

Signing out books

Now, LNC had picked up the books I brought from USA, the day previous, but Campus Chief came to me to say “you know, if this course wants to use these right away, you should get some of the ECG books back before we start checking them in” which of course was sensible. So the five books on ECG interpretation got signed out to the five groups from furthest away; and the Bhaktapur group will enjoy the chance to study their book without coming all the way to LNC. I presume each group will use this one book by studying it as a group – forming their own small seminar as they share the knowledge inside. Nepali college students are used to sharing books this way. Each student left class with homework, ten more rhythm strips to analyze, and they will help each other. This is the nice thing about the stretched out format. I still am ‘old school’ when it comes to ECG, and reinforcement over time is the way to go with this technical skill.

Rhythm strip examples from 1975?

Next week’s class starts with a quiz in which each student draws the cell activation cycle and cardiac conductive system from memory. And we’ll work our way through the conductive system. Part of each day is to puzzle through the rhythms, with help from the group, and get feedback. I once worked with somebody in Seattle who taught ECG solely by lecturing, right up til the exam; I thought she was incompetent, and in truth, people that “learned” from her didn’t do well. (She would then turn around and blame them for their low score.) For me, I don’t just simply show them the strip and tell them the answer, it’s an ongoing exercise in developing the ability to see a nonverbal phenomenon and name it, like Adam in Genesis. I still use a version of “The fisherman’s handout”, now updated with new AHA recommendations.

In Maine I always taught a CCU course every year, even during those years when our staffing at RFGH was stable, and over the course of ten years I actually taught this content to about 135 Maine nurses. (Mostly in Skowtown and Waterville, though one time I used the statewide ITV system to teach forty two at a distance). From the beginning of my time at RFGH, Bob Kaschub instructed us to save interesting rhythm strips in a little box. Samples harvested from this trove served as the class examples in my earliest classes, and I have reused them all these years. In other words, the Atlas of strips I use includes samples from patients monitored in the 1970s. Okay, the treatment has changed, but we were the same species then that we are now, and the pathophysiology is the same.

After lunch we changed the seating so we could demo the first two “mega-code” scenarios, one in which we used the imaginary defibrillator for imaginary ventricular fibrillation; we started an imaginary IV and gave imaginary CPR. For the second scenario a volunteer experienced imaginary chest pain which we fixed by administering imaginary atropine to reverse the imaginary bradycardia.

Dealing with stress.

Prior to that, though, the usual pep talk about performing on stage, in front of peers. Dealing with stress. A million times worse than simply public speaking. In real life, among critical care nurses, reputations are made when those around you observe how you do when the shit hits the fan. Do you freeze? Can you think? Did you act like a jerk? Do you lend a hand when the ship is sinking? Only when you pass the test by performing, do you pass the initiation into the tribe of critical care. At RFGH we used to call it “becoming a grownup” and I think many critical care units use similar terminology. A grownup can be trusted alone with a patient and a defibrillator. In USA we drill and drill and drill the youth of the tribe. The elders of the tribe have declared it to be so!

Here we are, teaching people how to do a set of complex psychomotor skills in a situation where they will ultimately be under a lot of pressure, high stakes. They will have to work as an improvised team, no two scenarios play out the same way, and in real life the patient frequently dies in which case you talk with grieving (or even angry) relatives immediately. During the learning phase we have to create a safe space for skill acquisition. The pep talk is where we begin.

One small joke in Nepal is about the phrase “Bahadur” – meaning “brave” – used as a caste name by the warrior tribe from which the Gurkhas are drawn. ( Some of my class members come from that ethnic group, and they enjoyed the acknowledgement). I asked for students to step forward if they felt bahadur; five of the more experienced students came forward for the first impromptu scenario. The one who wielded the defib works at the cardiac center and had actually done it in real life. She did the “I’m clear, you’re clear, we’re all clear” routine – obviously already well coached.

Then we did the other scenario with other volunteers and discussed. They did okay since the scenarios were simple and successful. I told people to Google “mega-code” and read whatever comes up. (I invite readers of this blog to do the same.)

Each week the class will spend part of each day doing megacode scenarios and discussing the nuts and bolts of actually functioning in an emergency. The plan is to focus on the AHA’s 10 scenarios from the ACLS curriculum. They will be grownups by the end.

After the bradycardia scenario a student asked why we didn’t use the defibrillator after we called for it. I had to explain that real life is an exercise in finding out what is needed and applying and that there are many scenarios. We didn’t use it because we controlled the situation before it deteriorated.

We’ll get there.
Each group will serve as a self-contained team and they will develop confidence. It was a fine way to get through the after-lunch period. Gave them a taste of what to expect.

The docs from NSCCM decided not to co-sponsor the course after all. They sent me a message saying to proceed with the course (!?!?); they would send a member to observe for a day and report back to their group. Maybe in future.

It was a long day but fueled by Chiya the class seemed energized even at the end. They sent nice messages afterwards. Next week they will each bring a pillow. I am told there are less than a dozen CPR mannikins in Kathmandu and most are broken. The pillow will serve.

Next week will be busy

After class, representatives of the BN students of LNC came to talk about doing a version of this, just for them. We agreed on a compressed set of dates, starting this Sunday (!). There will be 19 in that group, and they are giving up holiday time to do this. Next week I teach six days in a row.

Sobering story at lunch
A friend of a friend of a friend is a Nepali doctor who works in a remote area. I met him for lunch Thursday. He told me the story about how an inadvertent death happened at his hospital, then two hundred angry people gathered outside the fifteen bed hospital. The five nurses and doctors inside were afraid to go out. Outnumbered. They felt – a bit threatened. Concrete example of a challenge faced by health workers in rural Nepal. Now *that* is pressure that not even I can teach a person to deal with. The situation eventually cooled off when the political authorities showed up and encouraged a lawsuit.

All in all, I was happy with the first class day.



About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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3 Responses to Initiation into the tribe of Critical Care Nurses starts – now…..

  1. gaynor sheahan says:

    I enjoyed reading about the “nuts and bolts” of how you’re running the course, Joe. Will be interested to read more of the practicalities, especially how you plan to organize 75 nurses for hands on real patient experience. Will be quite a challenge I think, but you have years of teaching and clinical experience plus awareness of how things can work (or not) in Nepal. Thanks for sharing that level of detail, all very useful. Will definitely be stealing ideas for the future…..Glad that things are going so well.

    • Thank you for this. I sometimes wonder whether the minutiae of teaching are dramatic enough to share, it’s nice to meet another aficionado. I have not worked out all the details yet! One plan is to ask the students to go to their workplace and query the matron as to whether I can bring a small group there on some day, outside of class. And afew students offered to do just that. In Tansen I have taught CPR to forty students without using a mannikin. It’s all about your ability to do make-believe……

  2. gaynor says:

    Mega code isn’t a term I’m familiar with – I don’t think it’s one used in Australia or UK. We call it a Mock Code, and sounds pretty much the same as you describe. The most interesting Mock Code I’ve been involved it used a very sophisticated manikin which told you he had chest pain and made appropriate sounds such as vomiting etc. A twist was that the person “running” the code was blind folded (to mimic being a doctor at the end of a phone advising junior staff) so reliant on being fed accurate and calm information. It was a very interesting exercise and really stretched the person giving the information to the one blind folded, who then had to make decisions and direct the way the code was managed.

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