PALS renewal today was downright frightening

  1. Our renewal classes have nurses from clinics, wards, heme/onc, EDs and PICU at the same time because we are a tertiary center.

    For our scenarios, my group consisted of floor and clinic nurses, some doing their first renewal and some doing the last of their career (one nurse actually stated that).

    Now, I wasn't expecting them to come out of the gate swinging and run a flawless megacode but some of them couldn't so much as identify a shockable rhythm!

    • We pushed adenosine - not amio- for VT with a pulse, complete with peer-peer confirmation of weight based dosing.
    • We did unsynchronized cardioversion.
    • We did 3-4 rounds of epi and compressions for pulseless VT before someone suggested that it was shockable.... apparently several of them misunderstood PEA to generally mean ANY electrical activity without a pulse, therefore pulseless VT was PEA and they simply ran that row in their PALS card.
    • We gave nebs, fluids and finally Benadryl for what was clear-cut wheezing anaphylaxis.

    And the PICU instructor allowed all of these f-ups to happen and even gently guided a discussion about the correct approaches afterward rather than prolonging the scenario or pulling anyone aside.

    And when it was finally my turn I got sacked with some kind of spontaneous cardiogenic shock nonsense that I had to start on nitro and inodilators before she'd let me quit talking/guessing.

    I understand that lower acuity areas don't get the benefit of frequent exposure to critical illness and fulminant deterioration, but A) that is the point of ACLS and PALS and B) this was downright painful and negligent. Hell, I recognized one the nurses as having cared for my daughter during an admission. Now all I'm gonna worry about is whether she's itching to push amio for my kid's SVT or some other made-up treatment.
    Last edit by Euro_Sepsis on May 18 : Reason: Formatting
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  2. 15 Comments

  3. by   meanmaryjean
    If you were part of the mega-code- why didn't you speak up? You keep saying 'we'. I'm assuming you were part of 'we' and a member of the team.
  4. by   Euro_Sepsis
    I'm not there to teach, and each scenario is intended to test the "team leader"; giving away answers as a team member doesn't help them. These weren't small mis-steps that I could politely interject ala the AHA "knowledge sharing" vignettes. These mistakes were major concept failures that required book/classroom leverl remediation.
  5. by   Pixie.RN
    You could file a complaint with the training center; I don't believe those can be anonymous, but it's an option. I don't like the "everyone passes" classes either, because it sets nurses up for false expectations when they take TNCC or ENPC — not everyone passes those.
  6. by   meanmaryjean
    Quote from Euro_Sepsis
    I'm not there to teach, and each scenario is intended to test the "team leader"; giving away answers as a team member doesn't help them. These weren't small mis-steps that I could politely interject ala the AHA "knowledge sharing" vignettes. These mistakes were major concept failures that required book/classroom leverl remediation.
    Would you then not speak up in a real situation? I'm guessing you would. Not discounting your observations about this being a major concept failure- because it sounds terrible. But in mega code, you are to act as you would in real life up to and including pointing out error to save the patient from further harm.
  7. by   JKL33
    For years my experience has been that when we break into groups for the megacode portion, we are instructed that the megacode scenario is to test the team leader. We are specifically asked to await the team leader's direction and specific instruction...this is to allow each participant the benefit of thinking through each step without some hot-shot taking over and running all the megacodes. It is also, to some extent, to encourage participants to take it seriously and prepare accordingly. During ours, if the team leader gives instruction that is quite off-track the facilitator will address that. If the team leader does give me a specific instruction that is 'on the right track' but not completely correct (such as "JKL, please prepare to administer [wrong dose] of [correct med]"), I would clarify at that time. But, at least the way our organization runs ACLS/PALS class, if the team leader doesn't state, "begin chest compressions", no one begins chest compressions.

    I do agree with this. IRL, if one has ACLS/PALS certification, then it is not okay to rely on the idea that surely someone else will know the basics of what to do. This is two-fold - not only is that individual unlikely to be highly effective in performing ACLS duties during a code, s/he also can't help or correct any of the other ACLS providers who may also be relying on "someone else" to know the basics....and there may be more than one at any given code if we're saying it's okay to pass without knowing what you're doing.

    Keep in mind I'm not referring to someone who is a little anxious during the megacode, I'm talking about the one who clearly can not recognize a shockable rhythm, etc.

    I realize there are legitimate differing opinions about this; I have a good friend who says that ACLS/PALS class is for gaining knowledge, not for evaluating knowledge. I feel it is for exposure, learning, and synthesizing the information, and then practicing putting it all together in one's own mind. Otherwise why not just make it one more thing in the ever-burgeoning orientation binder, or part of the organization's online competencies?
    Last edit by JKL33 on May 19
  8. by   ~♪♫ in my ♥~
    Quote from Euro_Sepsis
    Now all I'm gonna worry about is whether she's itching to push amio for my kid's SVT or some other made-up treatment.
    Well, the good news is that providers determine which meds to give, not floor nurses.
  9. by   Medic/Nurse
    I think a 'full stop' would have been in order after the first *****. I would have asked, CLEARLY and without UNCERTAINTY, if the TEAMLEADER is getting ready to administer a med that will KILL a patient, should WE speak up or WILL YOU, as the testing proctor?

    Cause this is testing for the TEAM LEADER — correct?

    Yeah, warm & fuzzy PALS and ACLS to that degree is NOT beneficial in testing that isn't corrected, nor does it strictly follow AHA guidelines. The guidelines call for failure where necessary, remedial instruction/retesting — not allowing students to just willy-nilly spewing of nonsense without understanding what/why they are doing/treating.

    Holy Mother of Dog

  10. by   Medic/Nurse
    Quote from KindaBack
    Well, the good news is that providers determine which meds to give, not floor nurses.
    Yeah, no. Not gonna get a pass. Are they ACLS/PALS and expected by policy to provide care or not? What if other "providers" don't get there for 5 minutes due to delay or get caught in dueling codes (even had three go off neat simultaneously once) — guess the PALS/ACLS floor nurse get a PASS? Prolly not. But, I'd check that policy.

    Crash Carts are most everywhere for good reason. If they are carrying the paper, they need to know how to run the play and which ball to carry. Heck, even which endzone is the one that is for the "home" team.

    Be ready.

    Cause if you are expected to be in the class, you might have yo be "it". At least for a couple of minutes.

  11. by   OldDude
    I do think the PALS recert classes should place emphasis on the profession of the participants. For instance, I don't think, under any circumstance, a RT would initiate administration of any emergency medication or defibrillate someone. Likewise, I don't think the nurse practice act allows nurses to prescribe medications "unless it's a real emergency and no doctor is available." I've been PALS certified for 18 years so I've been through a few recerts with nurses, RTs, MDs, and Dentists, and I think the patients would be better served if emphasis was placed on the traditional roles and responsibilities in a code. In some instances it seems the only outcome of the megacode scenarios is to feed the ego of the instructor.
  12. by   Euro_Sepsis
    I agree. I'm constantly annoyed at AHA's expectation that any PALS provider be able to essentially diagnose ARDS, order imaging and/labs, inotropes and pressors, etc.
  13. by   adventure_rn
    Quote from OldDude
    I do think the PALS recert classes should place emphasis on the profession of the participants. For instance, I don't think, under any circumstance, a RT would initiate administration of any emergency medication or defibrillate someone. Likewise, I don't think the nurse practice act allows nurses to prescribe medications "unless it's a real emergency and no doctor is available." I've been PALS certified for 18 years so I've been through a few recerts with nurses, RTs, MDs, and Dentists, and I think the patients would be better served if emphasis was placed on the traditional roles and responsibilities in a code. In some instances it seems the only outcome of the megacode scenarios is to feed the ego of the instructor.
    Quote from Euro_Sepsis
    I agree. I'm constantly annoyed at AHA's expectation that any PALS provider be able to essentially diagnose ARDS, order imaging and/labs, inotropes and pressors, etc.
    Definitely agreed. I'd also add that in real life scenarios, many people who are PALS certified would never be expected to run a code. If you're a peds floor nurse who works on a unit adjacent to a PICU, and you know that if you called a code that actual PICU nurses and peds intensivists would be there in seconds, you probably wouldn't be as worried about being a PALS expert. I'd be more concerned if the providers you described in your PALS group were PICU nurses or peds intensivists.

    The NICUs where I've worked have only required NRP, although some NICUs require PALS. If I were to ever required to be PALS certified as a NICU nurse, I would honestly only be knowledgeable about the parts that pertain to neonates. I would probably bomb a megacode on a 12 year old, but does it really matter if I will literally never be caring for a 12 year old in practice?

    Also, as an outsider can I just note that the fact that the sim scenario is called a a 'megacode' is kind of hilarious?
  14. by   JKL33
    Quote from OldDude
    I do think the PALS recert classes should place emphasis on the profession of the participants. For instance, I don't think, under any circumstance, a RT would initiate administration of any emergency medication or defibrillate someone. Likewise, I don't think the nurse practice act allows nurses to prescribe medications "unless it's a real emergency and no doctor is available." I've been PALS certified for 18 years so I've been through a few recerts with nurses, RTs, MDs, and Dentists, and I think the patients would be better served if emphasis was placed on the traditional roles and responsibilities in a code. In some instances it seems the only outcome of the megacode scenarios is to feed the ego of the instructor.
    An ACLS RN would be following a very specific and well-known protocol that is part of the facility's policy, not "prescribing medications". The whole purpose of the class is for "a real emergency", such as one that happens when the doctor or other key team members is/are tied up or not yet present. I would expect anyone who has passed the class, including an RT, to shock or place pads in anticipation of shocking. I guess there's wide variation in what's expected from place to place.

    I don't disagree with the idea that it might be more helpful if roles/responsibilities were emphasized; that would be something different than what ACLS has traditionally been. But what we're talking about right now is people who basically only know and only expect to ever actually perform BLS, being passed through ACLS without being able to recognize the conditions or know anything to do for them besides check a pulse and start chest compressions. People do sometimes get remediated/retake ours.

    ED nurses always get the hardest scenarios, but I've never been humiliated by any instructor, even though they have some good-natured fun trying to make us think. They are very helpful to and gentle with those not working with any critical care patients...but still don't let people just watch VT/VF on a monitor for several minutes and not at least verbalize the appropriate tx and try to follow the card (an example from my most recent recert....)

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