part 4: teaching ACLS in Low Resource setting “give me a sharpened stick and a bare patch of earth”

So – you think you are a critical care cowboy and you are cool because you learned all kinds of derivative cardiopulmonary values and numerical formulae?


None of it is much use in a Low Resource Setting.

True story: in a missionary setting we once had a foreign surgeon come from a world-class 1,000-bed hospital where he’d had a surgical research fellowship. We were at a mission hospital in rural Nepal where we did not do central lines. It was – rustic. But I thought we gave good care, all things considered.  The people on rounds included a UK surgeon from Oxford, some Nepali surgeons and MBBS students, and – me. On the first day of morning rounds, the new fellow interrupted the British guy and started to lecture everyone on the utility of Swan-Ganz catheterization for this or that patient laying in front of us.

He didn’t get it.  The new fellow immediately made us all wonder as to whether he would be able to function at all. The rest of his story is told in my first book, The Hospital at the End of the World.

Yesterday’s quiz

Nobody tried to answer the questions on yesterday’s quiz. that does not surprise. The cheese is still in the mousetrap. Oh, I know I got hits. But nobody was willing to take a stab at it. okay. here are the answers. In no particular order.

– if ya wanna be a talking head behind a podium while the group sits there passively but doesn’t take notes, go ahead. But don’t expect that anybody learned anything. PowerPoint is not the best in an Asian classroom, if you ask me. you’ll be lucky if the power stays on the whole time; and you are expecting the students to change a lifetime’s practice in learning a certain way. You’re better off drawing on a whiteboard while they take notes, and stopping every now and again to have the check what they wrote. If you haven’t read Against the Tyranny of PowerPoint, it’s about time.

-there’s been recent evidence to suggest that by actively taking notes while attending a lecture, you activate difference parts of the brain than by relying on a keyboard. adopt a lecture style which encourages the students to hand-write the notes – the way they always have. DON’T bring a blizzard of handouts. DON’T give a whole bunch of photocopied articles, photocopied tools, photocopied stuff with dense texts. the vast majority of students will not read them or learn from them. They’ve been taught to rely on audio and psychomotor (writing) and you aren’t going to change it.

– build in as many ways for the stronger students to heal the weaker ones “get it” as you can think of. when you lecture in English, allow time for them to discuss in Nepali. Or, ask somebody to re-describe it in Nepali after you give them a chunk. Or, sometimes you will realize there is a continual murmur in the class – that’s because they are clarifying in in Nepali while you lecture in English. just let it happen. the murmuring is better for learning.

-divide the class into teams, at the very beginning. appeal to the students to work with each other within the team.

– at the beginning, clarify your expectation for leaving and re-entering classroom. be sure to give ample breaks ( something surprisingly difficult to remember for a new teacher).

-when you are evaluating your results, if you find yourself saying shoulda woulda coulda about the students, that means it’s you who needs to adjust. read the ancient classic teaching book Analyzing Performance Problems by Robert F. Mager and Peter Pipe.

– I go to many parts of Nepal, not just Kathmandu. I always start with a round of introductions. we go around the room. I’m being friendly of course. But I’m also assessing the English skills of every student. In rural areas you will have fewer with good English. see to it that they are engaged. Believe it or not, I have met a number of students for whom I am the first native English speaker they have met face to face. they need more consideration.

– I found a translator for my single most important handout, chapter 3 of the ACLS manual. It’s now in Nepali. cost $$$ but worth every penny.

-presenting the material is not the same as teaching it. teaching the material implies that it was learned.

  • learn to “code switch” – this is an absolutely critical care skill. read about it here.

Oh, and students here hate exams. Like everywhere else.

Where does the sharpened stick come in?

the one to use with the bare patch of earth? thanks for asking!

For Nepalis, the so-called lack of technology in education, and the fact that so much education can be conducted without a blizzard of paper,  has made them develop a system of learning that overcomes these obstacles.

For the videshis, know that if you are a really good teacher, the lack of fancy equipment does not automatically stop you from teaching any more than it stops the Nepalis  from learning. so – sharpen a stick, and let’s go!






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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