part 5: finally, the “Pearls” of teaching ACLS in Low Resource Setting

Muraho to my readers from Rwanda! My blog stats tell me I am getting a lot of hits from that country. Please make a comment below and tell me who you are. I am very curious. Welcome to this page. How am I doing?

UPDATED June 2019 with more links.

Finally, the Pearls.

Read the first four parts to this series. Everyone wants to know how and why I teach Advanced Cardiac Life Support (ACLS) the way I do. I’ve been happy that my approach gets such positive response. My approach did not just “happen” – I’ve been teaching this stuff since 1980 in USA.  If you go to my YouTube Channel you can see short clips of the students actually doing it. I made a playlist of various groups as well. They do the scenarios in Nepali language.

While you are reading, click here and read about my second book.  It’s a novel – not a scientific treatise.  I used fiction as a vehicle for passing along the eternal truths of working in a Low Resource Setting. the plot is based on the twists and turns of a good Bollywood movie….Buy it.

you know you want to.

Here are some actual tricks I use to teach a South Asian group. a set of decisions I have made that allows me to proceed. others may make their own decisions. good for you if you do!

– chapter 3 of the ACLS Manual is translated into Nepali. on the first day we spend 45 minutes going over this in detail, because it emphasized teamwork roles. they are told they will be judged on teamwork and this handout tells the scoring criteria. ( if you want the document, send me an email)

– we break up into teams. they choose a team name. they will stay with this team including for the final exam.

– they are told from the beginning that there is a final exam and if they don’t pass there is no certificate (OMG!)

– we don’t have CPR mannikins. instead, I use inflatable balls to pump on. we use the tune “ready” instead of “staying alive” though sometimes we use “Resum Firiri.”

– we keep lecture to a minimum. a short lecture then find a way to do some psychomotor exercise that applies what the lecture was about.

– for ecg, I do go over in painstaking detail about how to count the little boxes. it is a mistake to jump to jump into criteria for differential dx of rhythm unless the measuring system is down and locked. (“one little box is 0.04 sec,” etc) and we make sure each student gets it. as soon as a student demonstrates mastery, they are told to get up and join me in going around to help the others.

– we do the ecg dance.

-we have a pen drive party. students bring a pen drive and we download stuff from my laptop to their pen drive. I recommend a free 50-page pdf from Jason Waechter MD on his site Teaching Medicine.

– six rhythms. I have large laminated flash cards in sets of six, for the “onliest six rhythms” and we introduce these on day one. each group will have a scenario boss, who stage-manages each scenario. I choose the scenario boss from among the class at the beginning, and they have quick meetings with me to get their marching orders for the next scenario. this is a sort of leadership development.


AT 35 simulators. I do have 2 of these. they were an excellent investment. you need two monitors when you do this. they are nice because they portray the rhythms on the actual equipment as opposed to a card. I’m always careful not to hoard one for my own small group. if no monitors are available, we just use the flash cards.

ambu bags

Bag-Valve-Masks We own five of these. This is a critical tool! Every students learns how to use it and troubleshoot it.

-Ooh! OOh! (as Gunther Toody would say) in real life, people hate to use lots and lots of rythym strip printouts, because the ecg paper is expensive. when you visit any ICU, they always leave the paper-replenishment latch open, to prevent wasting paper. SO – even tough I teach a bit about how to do the paper analysis, it’s actually better and more similar to real-life if I have each group spend time reading the rhythm from one of the monitors, hooked up to the AT-35. I build time for that. Oh, and it’s very important to get people to learn how to discuss, so – don’t hurry them by giving the answer!

we don’t use mannikins for the mega-code. instead we have a student be the victim. the beach ball is off to one side and cpr is done on that.

– the course outline (found elsewhere on this blog) goes methodically through the ACLS protocols. I make sure I’ve covered the ten core cases.

-the final exam is conducted group-by-group, in front of the class. On the third day, before the final, about 90 minutes is built in for the students to sit in their group and review the course, in Nepali, which is important to solidifying the skills.

-I encourage students to video the megacode as a self-eval tool, using their smartphone. go to and you will find a whole bunch of videos that show what a course looks like.

– what do I not do?

I don’t give each student a fistful of performance checklists.

I don’t teach detailed cpr other than the four-step method in the protocols,

I don’t have a written final exam.

I don’t have a zillion dollars of equipment in use.

um, for safety reasons, we don’t even get near an actual defibrillator until day three, though we talk about it’s use from the beginning and use two dry-erase markers as stand-ins for the paddles.

I don’t use PowerPoint.

I don’t limit myself to only using an elite of trained assistants to run the small groups.  Oh, I ask people to come in from outside and help, but if they aren’t able to , we muddle ahead. actually sometimes its better that way.

I don’t pretend it’s a “real” USA ACLS course; but the knowledge is from AHA protocols.

If any participant gets around to taking an actual ACLS course, they will be much further ahead than a peer who has waited for an “official” course.


I am sure I will think of more. when I do, I will add.

Goal: I have this idea that we can create a large number of people now able to think of critical response in a different way than formerly. we’re still in the phase where the techniques and material are being shown to people for whom it’s completely new. At some point, we will have enough trained people so that the Nepalis can own this and take it over. I am trying to develop the skills of those persons who now wish to try out leading the small group segments.


why not join me in teaching this? we can create a movement for continuing education in critical care nursing in Nepal.


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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5 Responses to part 5: finally, the “Pearls” of teaching ACLS in Low Resource Setting

  1. I’ve enjoyed reading your teaching pearls. I confess to being a PP junkie….but that’s as much to do with the expectations of students here (and my supervisors at the uni) who like to be spoon fed and resent having to pick up a pen. I like to think I at least set high standards for my PPs and do lots of group work too.

    I’d be interested in a copy of the Chapter 3 of the ACLS manual you use. In English of course. How did you get it translated into Nepali. And the six rhythms you use?

    All good stuff I’m sure.


  2. Pingback: part 1: tips on how to teach ACLS in a Low Resource Setting June 1 2014 – “notes from the field” | CCNEPal 2014

  3. Pingback: CCNEPal Preliminary report for 2015, late May, part one, just the facts….. | CCNEPal 2015

  4. Pingback: May 28 report of CCNEPal part three | CCNEPal 2015

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