Okay, so at CCNEPal we model the course after the template published by the American Heart Association in their Instructor Manual. The course we teach at CCNEPal is NOT the “official” AHA ACLS course, though, because it is specifically adapted to Nepal. For example, we conduct the scenarios in Nepali; we debrief in Nepali; and we maximize the amount of time during which the students discuss the concepts in Nepali. (and hey, the certificate has the Nepali flag on it!) These adaptations are not possible in the American DVD-based course. For that matter, we don’t use the American DVD – because electricity is not always reliable.
TEN Core Cases
The A.H.A. says that in order to cover the bases of typical arrest situations, each course has to find a way to cover the “Ten Core Cases” during the two days of the course.
the ten core cases as listed by AHA are:
Here is what we do at CCNEPal
For the course, I always rely on “assistants” often recruited from among those registered for the session. I give each one a laminated card that lays out which scenarios we use, and this card serves as a “Cheat Sheet” to remind them what we are trying to do. ( it looks like the scenarios are unstructured, but – they are not. they are chosen in a well-thought-out sequence of easiest-to-hardest).
In order to meet the goals of the core cases, we actually run the groups through about fifteen scenarios. Here they are:
Simplest scenario: victim discovered in VF, receives defib ASAP and converts to NSR after 1 defib. (intended lesson: teamwork and communication. Start compressions!)
Victim is unconscious but does have a pulse. He is not breathing ( intended lesson: BVM only, 100% oxygen; apply Sa O2 monitor)
Asystole after defib. (intended lesson: keep doing compressions and airway, give adrenaline etc)
Recurrent VF – victim either stays in VF or goes to Sinus rhythm for less then 5 seconds and goes back to VF (amiodarone)
PEA: pulse absent, junctional rhythm (continue airway and compressions, 5Hs and 4Ts)
Bradycardia symptomatic B/P = 70 by 50, pulse 40, ( atropine)
Bradycardia with chest pain B/P 70 by 50, pulse 40. (Still has C.P. after atropine rx, needs MONA but skip N!)
Chest pain with normal rate – B/P = 160/110, sweaty. (do not be fooled by NSR and “normal” rate; MONA, 12-lead, and cath lab)
Chest pain with interruption by VFib – (start Mona, then defib then resume MONA after defib!)
Accidental morphine overdose (or also heroin!) B/P 160/110, resp 6/min; sa o2 74%, pinpoint pupils, (draw tracks on arm first! – rx =100% O2, BVM and naloxone)
Tachycardia: (stable) COPD victim with B/P 120/80, Sa O2 92%, anxious, bag of ausadhi….(rx: get consult from pulmonologist. Instruct victim to argue if team tries to give adenosine or cardiovert)
Tachycardia: COPD victim with pneumonia, coughing up sputum – sao2 86%, good vital signs, (treat with o2, salbutamol and antibiotics)
Narrow-complex Tachycardia victim unstable with B/P 70/50 and chest pain. Adenosine. (short period of asystole)
Wide-complex tachycardia victim with B/P 60/0 and chest pain – synchronized current.
As in #13 but victim develops VFib after cardioversion. ( rx = immediate defib)
The Secret Scenario is – a secret! But we do it anyway.
NOTE: some things we have adapted for Nepal: since there are few AEDs here, we don’t teach about the AED. Some of the usual drug doses are not the same as in USA, so we teach the Nepal drug doses. We have specific little exercises and games that help auditory learners ( a predominant style in this country) to succeed. Also, we don’t include the stroke algorithm.
On the back of the card, which we do share with students, is a list of team behaviors that lead to success. We coach them to do these things:
Reminder of key team behaviors
As long as victim has no pulse, continue compressions and don’t stop!
Continue compressions while waiting for defib machine to arrive. Continue compressions while 10-steps are being done.
Always recheck pulse after every med, after every defib, and every 2 minutes.
Give clear orders and courteous behavior by leader of team. Repeat all drug dosages back when they are ordered, give suggestion when wrong drug or dose is verbalized.
Don’t give Nitro if B/P was low, or recently bradycardia!
Resume MONA if interrupted by defib of unstable rhythm.
“lamo lamo sas phernos” – always when victim is awake.
Gather data before each decision. Don’t give med without checking B/P
Correct the BVM or compressions if not being performed properly.
Elevate the arm after each medication.
Check lead attachment to skin after each defib.
Always do ROSC protocol after success! Always debrief.
ONLY one leader at a time, leader is clearly identified. If the “discoverer” is also the leader, assign somebody else to do CPR. The leader does *not* give meds by themselves, always assigns follower to give meds.
Attention to the demeanor of the leader – confident, calm, clear.
The key in scenario-based education is the prep for the role play, and the quality of the debriefing after the scenario. You don’t need fancy equipment to excel at these components.
You can find the instructions for how to register for a course with CCNEPal, in other entries of this blog. Visit our FaceBook page!
And finally, please take time to read this review, in Nepali, of my novel, The Sacrament of the Goddess – Soon to be a major motion picture!