Why Should a Nepali MBBS doc take an ACLS course?

MBBS doc “Role Development” for effective critical care – what is it?

Critical care is not defined by a location (“ICU”) in a hospital. It’s more like a state of mind of the docs and nurses who provide life-saving emergency skill. It takes a certain kind of attitude to succeed.                                                         Joe Niemczura, RN, MS

CCNEPal has now trained about 150 MBBS docs, around the country. We’ve been active in Nepal since 2011, but until now we mainly focused on nurses. The two groups bring different things to the course, and so they do better with an approach that takes the background into account.  Here is what I learned from teaching at MBBS and post-MBBS level in Nepal. 

“Frame” of the ACLS course.

The word “Frame” is handy. It’s the one sentence to describe the overarching goal of the course. For nurses, it’s “we’ll learn about teamwork and communication during an emergency.”

For MBBS docs, the frame is “We’ll learn about confidence, problem-solving and leadership during an emergency.”

Notice that the drug doses, algorithms and ecg are not in the main “frame.” ACLS covers  those things, but the course is designed to focus on small group work for a reason – and the main frame reflects that. The typical beginner, taking the course for the first time, devours the drug, ecg and protocol info, and skips the teamwork chapter. Now, a person can master the technical details through personal study. But, the only way to master the leadership skills is to have a group and try to lead them. In ACLS, you will get that experience.

Role Play

A theme of the feedback from new MBBS docs who are in the “intern” role  is “nobody has allowed us any responsibility yet” – it’s because they are young. And for that reason, they have never given a medical order, or looked at their own style, or needed to actually make a critical decision in real time. In ACLS class we set up our role play scenarios with care so that everyone gets the chance to test themselves out. Even more, there is always a debriefing to get feedback on how they did.

The young doc who takes an ACLS course always learns about the focus and personal concentration that is needed in a critical emergency.

If the doc appears nervous – we tell them. If the doc barks out orders like the guy who stands in the door of a bus, we’ll help them work on this until they find a better way.  He or she learns to direct and control a team. When we have a group composed of a hundred per cent MBBS, they all want to be the leader at once, and it’s important to make sure the lesson about team is reinforced. One leader at a time. it’s not about showing off what you know, it’s about getting the team to work together.

Ke bhayo?

I’m not saying that a doc doesn’t need to know the drugs and protocols! They sure do! In an emergency there are many specific detailed orders that must be given; and for a young new doc, sooner or later they will experience a “ke bhayo moment” where the mind goes blank and no ideas as to how to proceed manifest themselves. It’s better to have it happen in a simulated situation first. We don’t know when during the training it will happen – but it always does sooner or later. When  the doc’s mind goes blank at a crucial moment, (such as forgetting to say “I’m clear, you’re clear, we’re all clear” just before defibrillation)  he or she gets the chance to feel what that’s like.

When we use this interactive approach, they’re less likely to have a brain cramp in the real world scenarios of the future.

Learning to react, learning to be flexible

This is another overarching skill. As you do a complicated medical procedure, you must reassess along the way and adapt your approach. You can’t learn just one recipe and always expect it will play out the same way. Adaptability is a slippery skill to teach! You can’t just say “Be Flexible!” or and over again. The teacher need to give  examples and allow the student to practice and test the parameters. ‎The scenarios impart the idea of how it feels to be in an actual emergency.

Topsy-Turvy

MBBS docs learn a specific way to approach a patient. Start by  introducing yourself; ask their name and why they came; review the HPI, family history and review of systems.  Then and only then do you develop a plan. In ACLS, we learn exactly how to identify a critical ill person who‎ needs immediate intervention; and ask questions later! We turn the usual approach upside down.

Affective Domain

All the things listed above go under the category of “affective domain” skills – they are attributes of the learner’s personality that go beyond simple memorization of facts. Success is critical care is only achieved when the doc is aware of the context of the patient. If I had to name one reason why every MBBS doc needs to take ACLS, it’s because there is no more effective way to arrive at the self-knowledge it requires from an advanced practitioner. This course teaches how to deal with ambiguity.

ACLS is the answer to a question you may not know you were asking.

And the question is : “where can I sign up for this training?”

Two places 

First, if you are Kathmandu.  There is one  Official American Heart Association International Training Center,  “The Center for Medical Simulation” a new company that specializes in this new mode of teaching.  They’re in Dillibajar.  Call 4616506. If you want to see what they do, “like” their FaceBook page, where you will enjoy the photos of previous classes etc. The Center is  just getting started, after a rigorous phase of setup and staff training. (for example The Center uses all the same equipment you would actually find if you took e ACLS course in New York, Boston or anywhere in USA). Courses at The Center lead to the official AHA ACLS card, recognized all over the world. An “official” card is especially handy for any MBBS doc who wants to compete for post grad work in USA, India, UK or Oz.

Second, CCNEPal offers a two-day course in these skills which is not the “Official” course. CCNEPal travels to various locations outside the KTM Valley. CCNEPal offers a course that is less expensive ( we don’t use the fancy equipment) and which has been adapted to Nepal. CCNEPal awards a nice certificate with the Nepal flag, not the AHA ACLS card.

DISCLOSURE: I am the person who is in charge of CCNEPal, but I am also in support of Center for Medical Simulation. There are 28 million people in Nepal, and there is lots of room for people who teach material with slightly different process.

About preparation for the course:

In USA, you would never simply sign up for ACLS they day of the course and walk in. the “rules” for participants are that each person must get the textbook in advance, and take a pretest. It minimizes stress and maximizes success. When I used to train people in USA, I had a sixweek course!

In Nepal, CCNEPal has not required this, but instead, makes it in to a 3-day course for nurses.