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.
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