ACLS

My last ACLS course was back in 2010, before I left Dublin. It was compulsory then for a medical doctor to be equipped with ACLS before they can be scheduled for on-call.

ACLS is an advanced cardiovascular life support, kinda an extension from Basic Life Support (BLS). Once pass, you will be given certificate (usually by American Heart Association) that will last for 2 years. It was covered by training grant when I was in Ireland, so cost was not an issue.

In Malaysia, ACLS is a voluntary course. As far as I can remember, even BLS was not made compulsory, to be done every 2 years, for health professionals - or at least I was not doing that. I remember looking at the cost to sponsor a medical officers for an ACLS course. For an AHA certified program, the cost is SGD800 for 2 days!! So, I can see why it is difficult to make it compulsory without any financial help. Local ACLS program, but not AHA certified is available in some hospitals with much lesser price, but it is not popular and not readily advertised.

Do we really need to know ACLS? Does it really make much different? Knowledge is one thing, and practice is another. I am sure, many videos on life support is available. One can be really good at the theory of life support, but putting them into a well coordinated team work that synchronised very well is difficult. Other advantages of getting ACLS done, for me, are:

1. Updating myself on latest guideline.

Latest ACLS guideline was published in 2015 (every 5 years). With every new guideline, there will be some tweak with the resuscitation steps and medication used. Compared to the last ACLS in 2010, the current guideline do not stress too much on airway/breathing. The main focus is minimal interruption of good chest compression and early defibrillation. Another change I notice is the discontinuation of Atropine (1mg) as resuscitation drug in asystole/PEA protocol. There is no more vasopressin as well. Now, only adrenaline/epinephrine left in that segment. There is also now post-resuscitation care, especially using targeted temperature managemenet (TTM) to cool down patients for cerebral/heart protection.

I was also informed of a randomised study in 2013 using steroids as part of the measures during resuscitation. It showed that steroid used improved survival to hospital discharge. However, because it has not been repeated since, it has not made its way into the guideline.

2. Medico-legal loophole

Imagine if we were involved in a medico-legal case, and we were asked regarding an unsuccessful resuscitation attempt on one patient.

The lawyer asked, "So Doctor, do you consider yourself competent in resuscitating this particular patient? How do you know?"

He further questioned, "Does your day-to-day job prepare you to be competent at resuscitation, without being trained formally?"

Without formal training, I'd have difficulty answering. It is the same reason why we were asked to document procedures such as IJC insertion. Complications are sometimes unavoidable, but competency is a separate issue altogether.

3. Understand the importance of teamwork

If everybody is trained, each individual will know his/her role - whether to inform the 2-minute mark for rhythm analysis, or to swap roles after 2 minutes, or the importance of close-loop communication. And I think most importantly, is the role of team leader to oversee the resuscitation process.
----------------------------------------------------------------------------------

I really hope that local hospitals will make ACLS course readily available, with more affordable price. I don't think we need AHA certification for that. Training will ensure that we understand why amiodarone is needed in every resus trolley, so people are not rushing to get it from CCU/pharmacy in every VF/VT, losing precious time along the way.

Departments or hospitals should cover part of the cost, wherever possible, to make sure that the on-call doctors are competent and confident with their technique. Make it part of departmental KPI if we need to.

All the best!

https://eccguidelines.heart.org/…/cir…/cpr-ecc-guidelines-2/

What to do if we hear somebody badmouth other people?

Although difficult, in situations when someone we know is being bad-mouthed at/backbitten, I do think we should practice these steps:

1. Do no join them furthermore by adding more stories that affirm what they are saying. (even if you don't like that person).

2. If we cannot say anything nice, either we keep quiet or leave the gathering. Beware that keeping quiet also can be viewed as something affirmative.

3. Even if we agree with what is being said, the rule is - that person is not there to defend him/herself. So it is not fair.

4. Repeat the sentence without the'bad words' associated with it. If somebody said, such a lazy person, typical (insert race) doctors. So we said, "What did the doctor do?" without the word 'insert race".

5. Change the topic/Distraction. "Did you hear about the news last night? It was so awful"

6. Diffuse the severity of accusation. "I saw that he was late this morning. There must be something happening. No wonder he was in a bad mood." or "Although his treatment is weird, I know he is such an experience guy. May be we should check the literature on the evidence"

7. Protect that person if you think what he did is genuinely good. "I think it is good that he complains. Though we don't like it, at least we know what's wrong and we can rectify it."

8. Lastly, even if you cannot intervene at that time, go to the person that was harassed if they are okay.

We are not perfect and there will always be slipped up from our sides. Be remindful to each other.

Micro-affirmation - subtle acknowledgement

Presumed I messed up big time. My boss was really frustrated with me, and although he said it was okay - I still have that feelings that not everything is okay. One day, in a meeting, to my surprise, the boss asked my opinion specifically on how best to address certain issues as he acknowledged that I have expertise than others may lack of. What would I feel?

In bridging the differences, certain good and sincere acts can bring miles of goodness. I was told that it was a common scenario in Dublin when one compliment each other dress or new shoes or hair etc. They seemed to be looking for something to compliment, and it comes naturally to them. Unfortunately, as if we can read minds - we call this sucking up to the authority. That makes us less likely to compliment each other, even in matters that is clearly cannot be considered as sucking up to the boss.

For example, if we compliment everybody, regardless whether they are our bosses or our workers - that is not sucking up. If we compliment each other and make sure we do not say something nasty behind their back - that is not sucking up.

One powerful tool is second hand praising. It means we compliment somebody in their absence. It iss usually viewed as genuine. And imagine a person called Iqbal said to us - "You are brilliant!", compared to somebody else said to us, "Iqbal told me that you are brilliant!". You decide which you prefer more.

Other examples of micro thing we can do, but it matters in bridging the gaps:

1. Acknowledge someone is there through greeting or smile
2. Give credit to others
3. Send notes of encouragement
4. Share positive feedback about someone with others.
5. Take time to show interest in and get to know someone new.
6. Affirm others' feeling about a situation.
7. Give opportunities for someone to speak.

Building, not burning bridges

In the era of internet and online, one thing I observe is the opportunity for everybody to say what he/she wants to say. Sometimes, the written words come across really harsh, unintentionally. Although many times, it was written intentionally to invoke anger - kononya siapa yang makan cili akan terasa pedas.

It can involve religious community, health professionals, anti-establishments, feminist or anybody who has strong opinions, and would like to impart their opinions on others. Many feel satisfied after lashing out arguments which tears apart their opponents, without realising - it did not change anything. It only increase their bitterness and resentment between the groups.

Psychologist and prophetic traditions have guided us to believe that change at personal level or belief usually comes from within, instead of being forced from outside. Things may look calm on the surface of a dictatorship nation, but any small opening will be used against the dictator himself.

The first step to at least bridge the gap is to understand, there are 3 modes of conversation: Debate, Discussion and Dialogue. The objective of debate is to get a winner (and a loser). And i think this is the majority of whats happening in social media, or in life even. The second is discussion. Although better than debate, discussion also aim to get a consensus or conclusion. And finally, a dialogue. A dialogue aim is to help understand each other, open our mind to options.

But often we see, a formal gathering called dialogue, but at the end, it turns into a debate - of right and wrong. How to make sure what we have is a dialogue - not a debate?

5 ways to build dialogue:

1. Positive intention
While talking to each other, put aside the our own judgment, first impression or any pre-conception idea. We want to sincerely know what and why the other side is thinking.

2. Ask clarifying questions
Dialogues involve a lot of clarifying question - "That is something new for me. Do you mind telling me more why you say that?" It gives the other side opportunity to explain and be heard.

3. Listen humbly
We listen not because we want to find points to counter attack. We listen to find the commonalities between different parties, and where is the differences, so clarification can be made.

4. Use pause intentionally
There will be times when we have urge to reply to a question immediately. Resist that temptation. Pause before answer.

5. Find common ground
There will always be a common ground. People argue about vaccine - but both groups want the best for their children. Different religious sects all want to enter paradise instead of hell.

So, next time you encounter an anti-vaccine or someone who really have different opinion and saying things that should not be said, what will you do? For me, pause is important. We need to pause (before replying) so we can re-think of our intention - that engaging in fiery conversation, most of times, will not benefit any. People won't change for something that was forced onto them. I need to pause so i can really hear what the other person said. Is there any logic behind that statement. Then instead of straight away telling them my opinion, probably i should ask clarification of why they say what they say. And if they want to listen to my opinion, I'll give mine, without having that 'micro-expression' that my opinion definitely is better than yours.

At the end of the day, it takes practice to have dialogue and to keep it that way. And it takes two person to do this. And we only have control for ourselves, not the other person. We can only do our best, and hopefully others will see that we are not there to combat, but to build bridges.

Unless you decide you want to debate, not a dialogue.

Hate The Sins, not The Sinners

An anti vaccine who is your daughter's teacher.
A politician who come to initiate something at your workplace.
A gay friend.
A colleague who drinks alcohol.
A Syiah who is your lecturer.
A Wahhabi who talks about evidence-based religion.
A Sufi who talks about the importance of being patience.

They all share similar things. There are parts that we may not like or contrary to our own principles, but there are also parts that we can benefit. Often, we fail to differentiate these things and they become all-or-none. When we hate a person/a group, everything that comes from him will be considered bad. Likewise, in somebody that we idolise, we cannot accept anybody saying anything bad about him. We know that everybody will have their sides of good and bad, and yet we choose to be blind.

How many people (that we previously look down upon) that turn themselves around and become much much better than ourselves today?

For me, a test to see if i am being a fanatic is to ask myself 2 questions:
1. Pick one person that I adore most (except the prophet as he is without fault), and i have to list at least 1 thing that I disagree with him.
2. Pick another person/group that I hate/do not like, and I have to come up with positive things about him/them.

If I failed to do these things, I consider myself a fanatic, and I have to reset my views.