All #Nepal nurses and MBBS docs need to read this carefully before viewing the videos of violence against health care workers in Nepal.
Specifically, CLICK HERE to see the video that shows what CCNEPal trains docs and nurses. https://youtu.be/jVDLXzwDWRA
(note: in the video, the scenario was a surprise to the responders. The woman wearing the turban is one of the teachers and she does know the scenario. Focus on the family interactions, not the execution of protocol).
CCNEPal
CCNEPal is the name for the courses taught by Joe Niemczura, RN, MS of USA when he is in Nepal. Joe was teaching at a PCL nursing school in Nepal since 2007 and there he learned that Nepali nurses and doctors are not taught to deal with emergencies the same way that USA nurses and doctors would be, so he set out to change this. He developed a three-day course (three for nurses; just two days for MBBS docs) to go over the Advanced Cardiac Life Support skills. He adapted the one from USA to fit the needs of Nepal.
Is thrashing included?
These needs included “What do when the patient party is unhappy with an adverse outcome and threatens to thrash the doctor ( or actually does thrash the doctor)”
This happens. It happens throughout Nepal, and Joe was asked about it everywhere he went. It’s a dirty little secret of Nepal health care. Some docs and hospitals deal with it better than others, and it is unfortunate that somehow the doctor gets blamed if it happens. An angry reaction from the “patient party” is not avoidable, but the skills to keep it under control need to be more widely taught in Nepal.
Lifting the veil of secrecy
Until spring 2015, this was called “the secret scenario” since there was a certain element of surprise involved, and Joe always asked people not to tell others about it unless they had already taken the class. Because this part was a “secret” the main way that people learned about the course was via word-of-mouth from people who had already taken the course. The secrecy allowed the course to possess an element of suspense and showmanship that left the participants with the feeling of having accomplished something amazing.
That was not enough.
In academic terms, Joe’s assessment was that the Nepal MBBS education needed to emphasize “situational awareness” more than it did. The MBBS docs are taught a methodical system of assessing their patient that is not helpful in a life-threatening emergency. Also, the focus is on patient physiology but it needs to encompass the entire microcosm of possibility that exists in an emergency room.
A recent intern who took this course said (paraphrase)
“Til now it hadn’t occurred to me that I would be directing everything – not just the resuscitation, but the whole team of helpers and also the hospital security and maybe even the police if there was a problem. From now on, I will be much more able to think about pro-actively enlisting the aid I need from all possible directions, not just trying to rely on myself.”
Joe knew he would be returning to USA in Summer 2015. And so, this spring he started to post more specific blogs and videos. Joe no longer followed the secrecy rule. You can find them on YouTube.
Warnings
There are some warnings about the videos and blogs.
First, the scenarios are acted out, not real, though at times the actors and actresses express deep pain or grief.
Next, sometimes people laugh, which may seem paradoxical. Be advised, any mental health professional will tell you that laughter can be a sign of anxiety, and does not imply disrespect.
The actors portraying the wife and members are selected the day before, based on their acting skills displayed in more mundane scenarios. They are given time to research and prepare. They bring their own costume ( making it more real and more fun). Nobody forces them to be in the role.
Third, we do this because simulation learning is a critical mode for adult learners such as interns, MBBS docs and nurses. It is an acceptable substitute for actual experience. There is an immediacy that can rarely be achieved using sit-down-and-take-notes lecture style.
Finally, the debriefing is critically important. When we do these as part of the class, we create a methodical build up to mentally prepare the participants to deal with emotionally-laden material – which may even trigger issues that are personal to them. We don’t just spring it on them and we always give people time to frame it in the proper context. That is handled during the debriefing process. This too, is new to Nepal.
Here is the link to the video. Click here.
Here is the link to the first ( of two) videos that show the debriefing. click here.
Here is the link to the second debriefing video, which highlights many practical tips in Nepali language, for dealing with this problem. It’s long, but worth it.
Future directions
CMC
CCNEPal wishes to acknowledge the support of Chitwan Medical College for this program. CMC is on the cutting edge of MBBS education in Nepal, and provided a living laboratory to explore the best ways to teach this content. CMC was the first MBBS program in Nepal to make this program mandatory for all final-year MBBS students (just before internship year). CMC has an expert staff who can teach this.
Nationwide throughout Nepal
CCNEPal has some specific conclusions
1) the training is effective and is needed by MBBS graduates during their internship year. They should not wait until the post-graduate time to get this training.
2) the skills of situational awareness are needed in mass casualty triage, and natural disaster. The MBBS docs will be on the front lines of this.
3) the program needs to scale up to include all medical schools and nursing schools. There needs to be a funding mechanism to support this during the scale-up phase.
There are twenty MBBS schools in Nepal. CCNEPal has worked with four of them. We believe that each of these needs to develop the expertise to teach this content, both the ACLS portion and the situational awareness portion, at a level of the curriculum earlier than at present (in fact, most schools do not teach this at all).
Join the campaign!
As of July 2015 we are re-evaluating how to move forward. Spreading the awareness is always a good step.
Here are things you can do:
Share this blog, and the videos, with as many people as you can.
If you are a medical student, ask your medical school about developing this.
If you have taken the course already and seen how the scenarios work, start using scenario-based education at your workplace.
We need to educate policymakers and leaders. If you can think of ways to do this, contact us.
CCNEPal 2020 
Just some of my reflections on the Situational Awareness video:
Of the Resus Scenario itself
Reasonable grasp of the basic skills by the participants but:
1. Initially not clear who was in charge of the resuscitation, and team roles
2. No obvious check of airway for obstruction or attempt to open/clear it, participants just went straight to breathing
3. Breathing was too fast – speed of inspiration and rate too fast, not enough time given for expiration. Emphasis now on respiration in resus is to avoid hyperventilation
4. Didn’t get a clear sense that they were following the 30:2 ratio? Seemed a bit random
5. No-one was counting and co-ordinating breathing to cardiac massage. This needs to be clear and out loud.
6. Greater emphasis needed on smooth transitions between those doing the cardiac massage to reduce time spent on interruptions/change of staff. There were significant pauses where cardiac massage was not being performed. This has been highlighted as a major cause of ineffective resuscitation.
7. Communication could have been clearer in terms of checks after each intervention followed by 2 min of CPR. Wasn’t clear if they were following the actual ACLS algorhythm?
8. Couldn’t actually hear what drugs were given. Instructions as to drug and dose need to be clear and LOUD by the person running the resus.
9. 4 H’s and 4 T’s covered as reversible causes? Couldn’t hear if they were. Again, instructions need to be clear and LOUD by the person running the resus.
Management of disruptive relatives
There is a great deal of research over a number of decades to show that allowing relatives to be present during a resus (with designated staff member to explain about what’s going on) is beneficial for the family (and often for the staff) and reduces the risk of misunderstanding and violence. I believe this research is relevant even taking Nepali cultural issues/differences into account.
It is interesting that relatives generally “call” for the end of the resus before the medical staff is inclined to.
It would have been better, once the relatives had calmed down, for them to stay in the resus room on a “good behaviour” premise not to interfere with the resus. Calling security and forcibly removing them is likely to provoke further aggression and a belief that incompetence is being covered up, as well as serving to deepen and prolong the grieving process for the relatives.
It was good though to see in the video when someone “senior” took charge and spent time explaining and reassuring relatives. Would have been better however for an experienced doctor/nurse to take this role with the most senior doctor or nurse staying to manage the resus. Not the best use of resources.
I’m not sure why the two women relatives weren’t allowed to stay with their dead relative once the resus had finished? Not a good look to be prising the fingers away and forcing them to leave after such a short time. This is highly likely to lead to aggression and a prolonged grieving process. This is especially relevant when the death of a baby or child is involved.
Current thinking in Australia in regard to ACLS competency
At my hospital we have switched from a yearly “ACLS assessment” (which involved a pass or fail and a huge amount of stress and time) to a “refresher” model which is as it sounds, and much less pressure. The focus is on more feedback and encouragement for multiple scenario practices for those staff who need it to achieve competency.
Latest studies show that yearly ACLS assessments don’t actually work in terms of competency. Most staff have forgotten the ACLS protocol and skills within a couple of months. Hence the thinking now to focus on refresher style practice scenarios more often than yearly.
To conclude, it was interesting to watch this video, and scenarios are great practice. This was a very realistic scenario. Looking forward to seeing the debriefing video.
Thanks for this detailed reply.
There is so much to respond to, here.
First and foremost, while the depiction shows less-than-perfect technique and team work, I decided to upload it anyway. That was not remotely the purpose of this specific scenario. In addition, for the segments dealing with family interactions, the intent was very different than what you perceived it to be. In ACLS and in simulation, every practical exercise does not need to be perfect in order to be a learning experience. In adult learners, it’s better to not teach and micro-manage every possible thing, which is the beauty of this approach. Over analysis leads to paralysis. To be honest, much of higher education in South Asia consists of over-analysis.
But let’s go through the points a bit more.
for points 1 through 9 above. The participants in the class did this exercise on day two. Unlike a USA course, they did not spend a month in preparation prior to day one. They were not given the details of the course in advance, an approach made necessary by logistical considerations that we could not control. So you are seeing beginners who’ve had one day of class prior to this.
Also, the team members are generally among the best students in the group.
Now imagine the idea that normally they would not be given even that one day of training, yet it is clear throughout Nepal that they are nevertheless considered to be ready as interns, to identify and respond to situations requiring ACLS skills. I suppose you could reframe this as “it’s not perfect but it’s better than nothing.” This gets to the very heart of why I do this, and why nurses and doctors respond so positively. with longer prep, or perhaps retaking the course in the future now that they have a better idea of what the experience would be like, they will do better.
Next, the portion dealing with the grieving family. This is an absolutely fascinating area of study and if I were younger I would write a PhD on the topic.
The team members were *not* told in advance that family grief and/or the need for counseling, would be part of this. This was and is a conscious choice I make, to emphasize the need. ( the students role-playing the family are chosen based on their acting during other scenarios, and given a day to prepare).
For that reason, I’m not disagreeing with you as to the critique of what would be the better way to handle the family. My assessment is, MBBS education does not address counseling in any depth and in fact, the students themselves don’t respect it as much as they should. Now after this exercise, they will be sparked to study it more and pay attention during the debriefing, to it. Without the opportunity to see how it would be done, they might not respond to a straight-ahead lecture.
So, thank you again. This video gives an excellent depiction of the skill level of young doctors whose next opportunity to lead a resuscitation in Nepal will be “for real” and I hope the viewers can appreciate the need for more widespread training in this specific area of medicine, both for doctors and nurses.
Hahaha. I think I was “set up” Joe! I think “over analysis” is not really relevant to my critique. You asked me to critique the video and I did.
Anyway, I think we’ll have to agree to disagree:
– In my opinion, even after only one day of training, standards/expectations could be higher for basic life support techniques. Missing out A in the ABC, for example.
– I believe, that in the right situation, and in the Nepali context, relatives could be accepted in the resus room. Research on this topic includes developing countries. I stand by my point that being excluded is more likely to lead to misunderstanding, a belief that incompetence is being covered up, and aggressive behaviour. The research began in the 1960’s and is exhaustive, but preparing the relatives, having them in at an early rather than a late stage, and having a designated staff member with the relatives at all times is absolutely key. Security can hover nearby if necessary.
– I also believe the grieving process is universal even if the outward customs are not.
I take your point that the team members were unprepared for the 2nd half of the scenario and that the debrief process would be an invaluable learning tool.
It’s good to remember that success rates for resuscitation, even in rich, well resourced countries, is poor to dismal. Figures vary from 1 – 3% (outside hospital arrest) to 10 – 15% (in-hospital with immediate effective CPR, cath lab and a well resourced ICU for ongoing care). These figures don’t reflect the quality of life of those who “survive”, and the enormous financial resources poured into training of health workers to achieve such a poor cost benefit.
Thank you for continuing the discussion. Where would I be without you?
If everyone always agreed on every single point and never presented alternative viewpoints, the world would be a boring place ( and of course, Nepal would have a constitution b y now….)
The video in question is not the only one showing scenarios, that I posted. You are invited to go the channel and look at the others. I made the conscious decision to post these despite the fact that the performance was less than flawless.
I agree wholeheartedly as to the success rate (“failure rate?”) of resuscitation. One of the key themes is to identify problems at an early stage and address them.
again thanks
joe
PS please write another guest blog!
and one of the debriefing videos is now uploaded. as you might imagine, the debriefing took longer than the actual scenario…. https://youtu.be/YqrLfCSkWeI
I should also add that I strongly disagree with you as to whether relatives should be in the resuscitation room, based on my personal experience as well as many many anecdotes. In carefully selected circumstances, sure why not. But the cultural context of Nepal is absolutely the wrong place.
But when the family lacks any education, and is highly emotional, they truly pose an added risk of injury to the health care responders. The widespread practice of maintaining security, is what’s needed.
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