Is ACLS ever “Warm and Fuzzy?”

Bandhs as a fact of life

Tuesday late afternoon before Wednesday’s daylong class, I was eating with a friend who casually mentioned there would be a three-day bandh.

Oh no. My plans for the once-a-week class do not allow for skipping or missing a week due to a bandh, so this was unwelcome news. To skip one session would mean that we go thirteen days before the next, losing continuity…. Ke garne, though – what can be done?

A bandh, for the uninitiated, is a protest in which all stores are shuttered and motorized transport is halted. Every intersection is manned by supporters, who harass (and will assault) motorcyclists or drivers that try to get through. It’s the favored means of protest here in Nepal. To organize a bandh requires mobilizing a lot of manpower.

That evening I got some phone calls inquiring as to the plan for the class, and I replied, we will have class if they cancel, which they sometimes do. In the evening I sat for awhile with Chris the videographer who is working for a Christian NGO, and he was trying to wrap his brain around the idea of a bandh, and how it “worked”. How do you find out about it, will any stores be open, do the phones still work, that sort of thing.

Chris asked one simple question which made me stop and think. “Which cause are they protesting?”


Don’t know.

You might as well ask, “why does weather happen?”

It had never even occurred to me to ask the person who told me about it, as to the reason for it. These protests are just a fact of life around here. The cause doesn’t matter any more.

Now it turns out this one was cancelled, the class members told me that nobody knew much about the group that called for it anyway; it was to protest petrol prices in some way. About a dozen members of the class did not attend yesterday, but 63 were there.

Onlyest Six Rhythms

I began with an ECG review for an hour while people gathered. We are on atrial and junctional rhythms, always a more challenging section of ECG. Nowadays, the ACLS courses do not address these rhythms, sticking instead to the “Onlyest SIx Rhythms” ( which is not a bad idea given the focus of ACLS) but I still include them for the critical care nursing course, to promote the idea of being systematic in applying analysis skills.

So what are the six rhythms, you ask? Well, they are:

Normal rate.

Too Fast.

Too slow.

Absent. ( Purists might say the absence of a rhythm is not a *rhythm*)

Ventricular Fibrillation.

Ventricular Tachycardia.

This has been a part of the Heart Association curriculum for twenty years, but for a long time it was buried in the manual and people did not really even mention this way of thinking about it – you’ve got to be thorough! – seems like I recall a discussion in 1998 or so, with one of the obsessive-compulsive ICU nurses (in Maine somewhere, during an ACLS class) in which the person was rejecting this sort of operational approach. You’ve got to teach all the ECG rhythms!

No you don’t. Even then I knew.

Anyway, I did go over this constellation of rhythms, and people worked on them together. I am told that many of the large group have photocopied the six- step handout for all their friends at various hospitals and it’s now being used around town. So – one goal of spreading knowledge is being met. Should have put more advertising on the handout!

There were short lectures on the feedback loop involving the carotid sinus/vagus nerve/ SA node and the CRTZ center in relationship to bradycardia; and also The Four Surfaces of the Heart along with 12-lead ECG reading.
This latter topic goes along with the Acute Coronary Syndromes protocol. Nepal, if you ask me, is headed for an explosion of smoking-related heart disease. One of the prices of development.

Also delivered a short lecture on PEA.

The afternoon of these class days is always devoted to “mega code” practice, in which small groups perform teamwork skills and get feedback about how they dealt with whichever scenario was on the table. It’s timed to keep them moving after lunch.

As always, this was fun and popular. I described it in previous blogs… Nothing new to report except that now we have two mannikins and I am utilizing my expat buddy Shirley Evans to run the other station. We emphasize one-rescuer BLS at the beginning of each scenario. We are setting themes for future weeks, and next week we finally get to VF/VT.

Master Class as a Model

For me, I think of Pablo Casals the cellist, or maybe Wynton Marsalis, when I do these classes. If I were a great classical musician blowing into town, the local music teachers would carefully prepare their best students to give a recital just for me, and to have a semi-formal chance to get feedback about the inner soul of a classical musician. Surely you have seen this sort of thing on the public television channel …. The leader is expected to be wise and generous and personable and nonjudgmental …. There is a component of self-aware role play the Master Teacher is expected to display, that presumes every virtuoso musician also possesses insight into the meaning of life…
The purpose of which is to coach and encourage.

And so, I am aware of the element and try to inspire them to practice more when they go home after class. Yup, that’s me folks.

Warm Fuzzy ACLS?

As to whether I have that mature insight into the philosophy of life – who knows. At home in Honolulu I am not afraid to manipulate or indoctrinate my students regarding how they should behave – and I do it even though I know it will mess with their heads at times. Let’s talk about the higher calling of nursing ….. Similarly in KTM, I throw in a good dose of warm fuzzy ideas about what I am teaching here.

In reality, ACLS is not the warm fuzzy approach to end-of-life issues. That would be “Hospice” – where the recipient says goodbye while sweet music plays in the background, candles are lit, the family holds the persons hand, and some nurse is quietly titrating a morphine drip in the background. All planned in advance.

This point was driven home yesterday by a simple act. Our second manikin is a full body doll whose plastic torso has female breasts, and the manikin comes dressed in a track suit. The first group in the simulation did CPR while leaving the top zipped, and also simulated defibrillation without unzipping ( which would create a small fire in real life). I called the whole group around, and showed them how to matter-of-factly expose the chest as we worked. Also to find the femoral pulse. When you’re in a hurry, there is not a lot of dignity. Done.
I could see people processing this.

If there’s soothing music in the background during the resuscitation of somebody whose life we are trying to save, , I’ve never heard it. ( I sometimes have tried to supply it but that’s subject for another day). This skill set is the one for when we want to live and see another day.

Bhairawa, The Terai

On a more mundane note, spoke with my hosts from Bhairawa, and there will be somebody to meet me at the airport. I will spend part of Saturday poking around the hospital there, the idea is to see their equipment, ask questions, and see if there are particular points of emphasis needed as the three days proceeds. I will try to get enough photos to depict what its is like. No photo will convey the humidity of the town though. Rice cultivation will be in full swing; every paddy in the town will be flooded. It’s flat enough that there is still a fleet of rickshaws in the town. On the distant horizon, the range of hills into which Tansen is tucked. These obscure the Himalaya.

The three days of teaching start Sunday. I am gathering my handouts today and doing errands.



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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2 Responses to Is ACLS ever “Warm and Fuzzy?”

  1. Fantastic story. I’m working towards low-cost simulation labs for low-resourced countries, and there are exciting products now available. For example, for learning how to deliver babies:
    Hopefully this trend continues for other products, such as for ACLS (and starting IVs, and learning to suture, etc…)

    • Thank you for this exceLlent link. On the YouTube sit (find it there by searching for “Joe Niemczura” I have a clip of us doing mega-code…. With essentially nothing. Now, in Nepal the sachools are attemtping to migrate to a B Sc nursing curriculum, as opposed to a PCL, and the Campus Chief was just telling me they need to upgrade their learning lab in a big way. I will go there to day and get some photos of what the present learning lab looks like.

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