nexus news | March 2016
NEWS, VIEWS AND INFORMATION
FOR APLS MEMBERS
In November of last year I travelled to Manchester to participate in planning around the new 6th edition APLS course developed by ALSG.
The timing of this meeting followed the publication of the ILCOR statement and was an opportunity to ensure our teaching remained consistent with these international recommendations on resuscitation. A major challenge for APLS internationally is that the different national resuscitation bodies around the world make slightly different interpretations with the result that “correct” resuscitation of a child in the UK would be viewed as “incorrect” in Australia.
Since November, the Australian and New Zealand Committee on Resuscitation have released our national guidelines. APLS Australia is now in the process of updating our materials. This includes the soon to be published and much improved 6th edition manual which will be edited to comply with Australian and New Zealand practice, the e-learning and the face to face course.
We are using this opportunity to update both content and some additional structural changes to the program. The timing is a little annoying having spent the past 12 months modifying the course for our own e-learning package. However, some changes had deliberately been left on hold waiting for ILCOR and the APLS 6th edition manual. So here we go again…
The Course Development Committee (CDC) will take the lead on implementing these updates to be progressively finalised over the coming weeks and months. The committee met last Friday in Adelaide. It would be premature to detail any of the changes but in general terms they will include:
- Modifications to day 1 of the program to better address neonatal BLS, make the approach to airway teaching more contemporary and promote a continuous approach to practice, acquisition and assessment of the skills required to manage cardiorespiratory arrest.
- While continuing to teach the paediatric specific approach to cardiac arrest and resuscitation, the actual procedure of defibrillation will be standardised to reflect adult practice. This will require filming new e-learning materials which will take some time but is seen as a priority.
- Trauma immobilisation, including c-spine will be modified.
- A more contemporary approach to trauma resuscitation including blood and blood product use.
Creating the updates, developing the materials and rolling out the changes will all take time. We would welcome any offers of assistance to be involved – contact Phillip Davies in the office who can get you in contact with the relevant member of the CDC.
Finally, in the meantime, I will remind everyone of the few small changes to resuscitation which we can and should incorporate into our teaching immediately:
- Compression rate in CPR should be 100-120 (previously 100)
- Hand encircling 2 thumb technique preferred over 2 fingers
Thanks to all our instructors and staff for your ongoing commitment to APLS through 2016. Have a great year.
Here’s a quick guide to running APLS scenarios using ALSi, for instructors yet to have a go with our new simulation units.
The guide explains how to get started, how to use quick picks, how to change things on the fly and some trouble-shooting tips.
We’ll soon have some video resources to run through the basics and demonstrate more of ALSi.
In the meantime, ask your fellow faculty members or contact firstname.lastname@example.org for support.
GIC candidates and instructors can now brush up on their teaching skills with the launch of pre-course online content for the Generic Instructor Course.
Follow the new GIC online learning tab in your User Panel for practical advice and resources on core GIC topics.
You can watch presentations by APLS Educator Jane Stanford on giving a lecture, teaching skills and giving feedback, as well as demonstrations of effective teaching and feedback methods.
The resources are available for GIC candidates, instructor candidates and all instructors.
Log into apls.org.au and find this tab in your User Panel:
By Setthy Ung
As the population of APLS Australia & New Zealand instructors grows, there is increasing capacity for its volunteer members to make a difference in other parts of the world.
Many of you have become APLS instructors because you believe in a cause greater than yourselves; to improve the standard of acute health care for children and to ultimately save lives through developing the systems of others.
Many of you will travel throughout the developing world and some of you will donate your time and skills to volunteer in their health facilities. I am certain those who have in the past or currently work in developing systems would all agree that in comparison to flogging yourself and others resuscitating every sick or injured child you can find yourself, the greatest gain for a developing country is when a teaching curriculum such as APLS can be implemented and spread across its entire acute paediatric health system.
Getting the idea from a mere thought of altruism to proposal draft, to full implementation and then on to long term sustainability can be a lengthy, resource intensive and arduous process. It can be very rewarding to both the population of children who will benefit from it as well as the volunteers who donate their time, energy, heart and souls throughout the process.
But how do you go about turning that light bulb moment into a reality? The following is a simple list of what I would recommend to others to consider before embarking on such a pilgrimage.
1 | SUSS OUT THE PLACE FIRST
Doing your homework first includes understanding what resuscitation curriculums are already in place (eg. Emergency Triage Assessment Treat - ETAT), what the state of the health system is (currently and predicted for the future) and what the state of the nation is.
Many developing nations may already have philanthropic parties or NGOs providing the WHO ETAT course which can both complement the APLS curriculum (eg. Airway opening maneuvers are taught the same) and contradict it (eg. Heimlich maneuver still taught by ETAT) thus there may be a need to sit down with the local health authorities to negotiate what APLS content you will teach and which content you will not teach until agreement between the APLS curriculum and national resuscitation guidelines or policies can be achieved.
Some health systems do not have any acute health care systems in place (eg. no acute hospitals) nor equipment to resuscitate (eg. no oxygen supplies, no ETTs or BVMs and no IV catheters) which may make APLS training moot as an APLS trained clinician without emergency equipment may not be able to provide effective care once back in their usual workplace despite being trained to do so.
If there is a lack of political stability (or worse open warfare), trying to implement the APLS curriculum would perhaps be futile. The success of any long term APLS project relies heavily on communities being stable enough to build equipment pools, develop healthcare networks and to retain its trained providers long enough to become instructors themselves to teach future generations. Wars and unstable governments tend to result in equipment going missing or destroyed, networks being disbanded, and healthcare providers being displaced from hospital environments (or worse targeted by aggressive factions).
Also, to consider is the level of tourism of the potential city or country. Even though most APLS Instructors are like-minded people who enjoy teaching others, with the exception of a handful who may have particular cultural experience or affiliations with the community you are investigating, at the end of the day most of the faculty you will try to recruit will be tourists. Thus, apart from the safety and security issues for your traveling faculty, you will need to consider how appealing the hotels, local food, tourist sites, airports and means of transport are.
2 | DO SOME HARD TIME
Just because you and the entire APLS Instructor membership think a community or nation would benefit tremendously from inserting APLS into their mandatory paediatric training systems, unfortunately doesn’t automatically generate buy in from the locals.
Earning a level of respect and credibility in the eyes of the local health care authorities and providers is of the utmost importance in trying to implement a self-sustaining education curriculum. In the long term, money nor the donation of medication supplies or expensive medical equipment can buy it either.
I think the best way to ‘pave the way’ is to display your own APLS skills and to give them snippets of resuscitation teaching by living and working alongside the local healthcare providers. The period required to do this may vary depending on how far away from acceptance you are as a colleague when you have started to develop a rapport. However, once accepted as a colleague and suspicions of hidden religious or political agendas have been dismissed, requests for you to contribute your APLS skills and knowledge will undoubtedly follow.
3 | FIND A LOCAL CHAMPION
At the end of the day, you will never be considered a ‘true local’ and unless you are intending to spend the entire project period of 5-10 years there physically, you will need a local champion to advertise, facilitate, encourage and help coordinate the first and future courses. Invariably, it will be one of the local senior doctors or nurses who the healthcare system already gravitates to and respects.
The person selected will need to have a pivotal influence within the local health system, be charismatic and ultimately have the qualities of being a good Instructor (and Course Director). It is hugely important that the right person is selected for this role as it will minimize the effort you will need to input to maintain then sustain the project. Once identified, this champion may then access the Paediatric Emergency Development Scholarship offered by APLS Australia to come to Australia to attend their own APLS Provider or Instructor Course.
4 | GATHER YOUR FIRST TEAM
Your first faculty will need to comprise Australian instructors who are experienced instructors and it is also wise to have at least some who have taught on international courses before to draw on their experiences when the unexpected occurs. The smaller the faculty the better, to minimize the perception of ‘invasion’ by the locals as well as make it easier to transport and accommodate. Unlike the usual faculty of around 12, I recommend a faculty of about 8 not including the course coordinator and course director. It means more work for everyone involved but the locals will get to know your faculty better and vice versa. If you can find instructors who are multilingual or speak the local dialect then it will give you better flexibility to assist candidates who may not have good English. A good mixture of age groups, genders and craftgroups (ie. Nurse instructors, Anaesthetists, Emergency Physicians, Intensivists, Paediatricians etc) also allows flexibility when allocating mentors when faced with unexpected cultural (hospital and social) challenges.
If there are already local APLS Providers trained in Australia, UK or elsewhere already but not yet trained as Instructors, they can be excellent support staff during your first provider course and invariably you will benefit by getting them to serve with your faculty.
The International Subcommittee handles a database of instructors experienced and interested in international courses and can help recruit your first and ongoing faculties.
5 | INVITE ALL THE VILLAGE ELDERS
Although it can be quite painful, when running the first provider course, I recommend making a song and dance of it and inviting all the local VIPs such as the government health official, heads of departments and even royalty if they are around. Not all will attend and some will send a minion in their stead but it will appease the local deities and assist in ensuring the maintenance and sustainability of the project. Even invite them onto the course as a candidate if they are of the appropriate background but god help you if they fail.
6 | PREPARE AS IF YOU'RE GOING INTO SPACE
Ensure that you spend some time prior to the first course (and I suggest even before leaving the country) that everyone is briefed on cultural issues and expected barriers. Travel insurance, mobile phone roaming activation and itinerary sharing with contingency plans for emergencies should be considered well before anyone steps on to an airplane.
Refer to DFAT and know the risks of the country you are heading into as you usually would do when traveling overseas. To make it easier on yourself, it is wise to choose a first faculty who are experienced travelers, who have traveled to the environment before and who even have traveled with other faculty members before.
Physically take your first teaching kit with you if possible. It may feel weird to carry manikins through security and customs but unless you have already ensured your first course’s venue has a full teaching set equipped through your own hands, I would not recommend risking having a teaching kit travel separately from your faculty. Developing countries tend to have the least reliable freight (and sometimes luggage) handling services so don’t put your first course at risk of not being equipped.
7 | BE PREPARED FOR THE EXPECTED & UNEXPECTED
Every course you run internationally, no matter how fastidiously you prepare something will go wrong. Good preparation will minimize the impact (eg. packing enough travel medications for you and your entire faculty) and ensuring that you are well-connected with your faculty throughout the entire travel period will be the best thing to ensure that no matter what calamity occurs you can all deal with it together as a team.
8 | START TRANSITIONING OWNERSHIP EARLY
Hold Instructor courses as soon as possible after Provider courses to take advantage of the momentum and enthusiasm many strong candidates your faculty selects to become local instructors possess immediately after their Provider Course. This often maximizes the donated time of the Australian Faculty that you have recruited and has traveled with you.
As soon as you have identified the future leadership and ownership of the curriculum, get the local instructor candidates to first shadow the Australian faculty then instruct the courses (including the Generic Instructor Course) themselves. Especially with the ‘train the trainer’ concept, they will need mentoring to eventually fully take responsibility for the sustainability of the courses.
9 | ASSESS & AUDIT
Encourage the Course Directors of the local faculty to collect data, course report and course feedback information from the start so that they can modify the teaching of and the content of their courses as a dynamic process to help improve the compatibility of the course curriculum to the needs of the particular health system being targeted for development.
Setthy Ung is an Australian-Khmer Emergency Physician for Campbelltown Hospital-Sydney, NSW. APLS Course Director & Instructor, Medical Volunteer for the Angkor Hospital for Children in Siem Reap-Cambodia, Cambodia and the Lao Friends Hospital for Children in Luang Prabang-Laos.
Selected photography by Tom Walwyn, Setthy Ung.
Has this whet your appetite for international work?
The Lao Friends Hospital for Children in the beautiful town of Luang Prabang, Laos, is looking for ED/paeds doctors at senior registrar/consultant level for future volunteering work.
The hospital is new with a 20 bed ward, 24 hour ED and close links to the APLS family. Setthy Ung is a regular volunteer, and APLS Australia founder Simon Young and Chris Sanderson are about to undertake a long term placement there.
If you would be willing to volunteer your time for one month to help train, supervise and mentor the young Lao interns and residents in the future, you can contact Setthy as a first point of call at email@example.com.
The updated – and eagerly awaited – APLS Australia app is now available.
The app is free, compatible with all Apple and Android phones, and you can download it here:
APLS for iPhone:
APLS for Android:
If you haven't tried the app yet it's the ideal way to keep APLS guidelines close to hand, with all our major algorithms available for quick reference:
• Paediatric Basic Life Support
• Advanced Life Support
• Cardiac Arrest Management
• The Choking Child
• Anaphylaxis Management
• Bradycardia Management
• SVT (Supra-Ventricular Tachycardia) Management
• VT (Ventricular Tachycardia) Management
• Decreased Conscious Level Management
• Status Epilepticus Management
• Cervical Spine Management
• Hyperkalaemia Management
• Structured Approach to Emergency Paediatrics
• Newborn Life Support
Elsewhere you can discover more about the APLS course, browse future courses near you and watch on-demand video from PAC conferences.
First launched two years ago, the app has more than 12,000 downloads worldwide and is now fully updated for the latest range of mobile devices.
Share, review, enjoy and let us know what you'd like to see in future updates.
Recently released videos include Joanne Morris's session on The Difficult Adolescent Patient in the ED from last year's conference (above), Sarah McNab's presentation on her landmark PIMS study from PAC 2013, Andreas Pflaumer discussing Sudden Death in the Young from 2014, and lots more.
You can stream the sessions on demand and access is free and open to all.
New presentations are released fortnightly via the paediatrics blog Don't Forget The Bubbles with a summary of key clinical points.
The complexity of not-for-profit companies (NFPs) is attributable largely to two factors: the nature of their stakeholder base and the fact that they are dealing in social outcomes.
The NFP is a unique entity. It comprises a mixture of volunteers and paid personnel all of which are hugely committed to their cause. The lives and welfare of real people are dependent on the quality of their collective work. NFPs therefore play a key role in the social fabric of our communities.
There are three factors that are critical to the success of a NFP.
- The first is people.
Fortunately, as APLS gets to be a more sophisticated entity, we are finding that there are more and more people with the skills we need with a desire to volunteer and work in this area and for our mission. Our committed staff and volunteer base are directly attributable to the strength of our company in terms of providing quality courses throughout Australia.
- The second factor critical to growth is maintaining standards and coherence in clinical teaching and organisational efficiencies.
We at APLS remain committed to maintaining the systems, course standards and accountability that you would expect from a for profit company of the same size.
- The third factor is growth and evolution.
It is critical for NFP to evolve, grow and change. We have seen and made significant changes to our APLS courses recently with the incorporation of both the VLE and iSimulate units into the courses. We are presently embarking on implementing certain of those developments into the PLS course.
It is difficult to envisage a time where at APLS we do not organise and conduct both the APLS and PLS courses. However, we must continue to develop and a way of doing this is to have a wider array of product offerings for our customer and membership base. The key issues are what form do these new products take and what is the nature of them. Another key question is what should be the duration of candidate’s time be devoted to these new products?
Should we for example have a short refresher course for those who have not done the APLS course for a number of years, and have not been part of a VLE APLS course? Alternatively should we be implementing/offering an Advanced Paediatric Course that goes beyond our present APLS course? Should we offer both courses to different audiences? Should we offer a hybrid course which seeks to cover both these aspects? How long should both the preparation and the actual time at the course be for candidates?
To that end, given the importance of such a decision for APLS and the valuable input we can get from our membership base, we will shortly send you all a brief survey on possible additional product offerings for APLS.
Just to confirm the APLS board have not made a decision on any of these matters in respect to additional paediatric courses, but they and I would like your valuable input prior to any considerations of any additional product offerings for the company to complement our APLS, PLS and GIC courses.