Report to Council Society for Acute Medicine (SAM)
Author:
Mark Holland
Subject:
MedicALS
Date:
August 2015
Introduction
A request was made by Dr Philip Dyer to Dr Mike Jones for the AIM STC and SAM to grant
approval for a training course called ‘MedicALS’, an acute medicine emergencies course.
The course is run by an independent, not-for-profit, charitable organisation called the
Advanced Life Support Group (ALSG). Dr Dyer is a faculty trainer on the course.
SAM have previously recognised courses for their contribution to training, most recently
IMPACT. However, in view of the perceived importance of SAM recognising and approving
courses, we need to make such decisions carefully. In this case, none of SAM’s Council
members were aware of the content and structure of the MedicALS course. Therefore, I was
charged with reviewing the course and feeding back to Council to allow a decision to be
made. I attended the second day of the course on 27th May 2015.
The original request from Dr Dyer is attached as Appendix 1 and must be read to understand
what we are being asked to consider. Dr Dyer’s mapping of the course to the AIM
curriculum is shown in Appendix 2 and a specimen programme in Appendix 3.
Having attended a course I feel that the disappointing performance of doctors at the AGM
conference , as described by Dr Dyer (Appendix 1) might in part be explained by the clinical
assessment process which MedicALS advocates through primary and secondary
assessments. The MedicALS method is quite rigid and if not followed correctly participants
will be deemed to have failed, which does not necessarily equate to poor or unsafe care.
Course Content and Structure.
The course is modular with a final assessment and certificate for those who pass the course.
The structure is similar to ALS. The core components include:
1. Virtual Learning Environment(VLE) – to be completed before the 2-day residency
programme. The VLE is comprehensive and covers the core content which is revisited
during the residency programme. The VLE is well designed but most importantly it
affords an understanding of the clinical assessment methodology taught by MedicALS.
2. Course Manual – issued to all participants. This is again very comprehensive and
complements the course, adding a deeper level of understanding. One criticism raised
by one of the participants was that the manual was out-of-date. This criticism was
technically valid, as the continual flow of new guidelines, the internet and electronic
information will always conspire to make any printed scholarly tome immediately
obsolete. However, the manual is well written and would be a worthy read for any
physician, regardless of status and experience.
3. 2 Day Face-to-Face Course (residency programme) – This is clearly the key component
of the course and is contextually embedded within the previous two core components; all
three components are complementary. This aspect of the course warrants the most
consideration.
2-Day Face-to-Face Course (residency programme)
1. Venue
The course is held at the world headquarters for ALSG in Swinton, a suburb of Manchester.
The venue appears to be two or three terraced houses converted into an education centre.
Space in the centre is only just adequate for a small audience (18 on the course I attended)
who breakout into three groups of six for small group teaching. Two of the rooms used for
small group teaching were too small for the task.
Catering for candidates was of good quality. Parking was provided.
I was concerned about the venue for a number of reasons. Dr Dyer suggests the course
would be aimed at CMT/ACCS/ST doctors. To make this feasible, in terms of logistics, time,
and money, the course cannot be run on a large scale from Swinton. Many of the
participants were staying in hotels, and coupled to the cost of the course (£550), this would
have major cost implications, especially when one considers that many participants would be
studying for college examinations and would also need to fulfil mandatory requirements such
as ALS courses or SCE.
It was my opinion that the quality of the venue, coupled to the cost of the course and
the logistics of holding the course in Swinton, would make large scale implementation
of the course very difficult. It is my view that to roll the course out nationally, akin to
courses such as ALS and IMPACT, MedicALS need to provide us with their strategy.
I would envisage this to be a form of a franchise model.
2. Content
The content of the course has two main strands.
Firstly, there is the assessment process. MedicALS teaches assessment using primary and
secondary assessments, with focused history taking. Whilst this method does deviate from
traditional ‘history and examination’, it does afford candidates a clear structure to assess sick
medical patients.
Secondly, are the topics. These range from ABCDE care through to specific scenarios such
as stroke, headache, GI bleed, chest pain, TLOC etc.
Overall, I was impressed by the content of the course. However, I did feel that
course would best serve emergency medicine trainees who need to learn acute
medicine as opposed to acute medicine trainees.
3. Teaching and Teaching Methods
Educationally, I thought that the structure of the course was excellent. As already
discussed, the triangulated approach of VLE, manual and residency works well. The course
has clear aims and objectives and the messages from the faculty are also clear and
consistent.
In the residency programme, the key techniques used are simulation (with role play) and
small group teaching. The programme afforded participants the opportunity to clarify
problems in faculty surgeries.
All participants were clearly allocated slots to undertake assessments in front of their peers.
The faculty members would critique in real-time. All participants were happy with this
process.
I felt that on the whole, the standard of faculty teaching was very good. Some
instructors were clearly excellent. For example Dr Dyer was able to take participants
out of their comfort zone but without making them feel belittled. However, some
instructors were too passive. On a couple of occasions inaccurate information was
used by faculty members for neurological examination techniques. I felt that faculty
with from an emergency medicine background lacked the thoroughness and attention
to detail of an internal medicine physician.
4. Views from Participants
Candidates agreed that the course was of a good quality. The main concern was cost and
value money. For those who could compare courses, IMPACT was seen as better value.
One participant had spent over £800 on the course (course fee, travel and
accommodation).
Recommendation to SAM Council
Based on my experience I think ALSG provide an excellent course in MedicALS. However,
at the current time I would not be happy to give an unreserved endorsement from SAM.
The issues we need to clarify and address are:
1. Cost and logistics - how can this course be rolled out nationally and affordably?
2. Can this training be implemented regionally through CMT / ACCS / ST programmes
which would address my concerns in point 1? Is MedicALS simply a mirror which
reflects failings in our current training processes? Is MedicALS a wake-up call for us to
improve our in-house teaching; simulation suites are now readily available?
3. Certification – participants on MedicALS receive a certificate for completing the course.
Do ALSG see certification for MedicALS as being akin to ALS or similar courses? If so
our endorsement of what is currently an expensive cottage industry product, albeit of
high quality, becomes even more important.
4. Whilst ALSG is a not for profit organisation, it is clearly the case that making this course
a formal requirement for trainees would generate significant revenue for ALSG.
We need to take this discussion forward. If we are happy that the teaching and content are
satisfactory, we should consider meeting representatives of ALSG to discuss our future role
with MedicALS.
Mark Holland
August 2015
APPENDICES
APPENDIX 1
09.12.14
Dr Mike Jones
Chairman for the Special Advisory Committee for Acute Internal Medicine
JRCPTB
Re: MedicALS Course (Acute Medical Emergencies Course)
Dear Mike
I was at the recent AGM conference in November at the Excel Arena in London. I was teaching acute medical
emergency simulations as part of the MedicALs course I teach for the Advanced Life Support Group. MedicALS
exists to teach the practical procedures necessary for effective management of acute medical emergencies.
MedicALS is a 3-day course comprising of a flexible one-day on-line component (VLE) and a two-day face-toface course. The plan for the AGM conference was for us to teach 4 or 5 simulations (see examples attached).
Unfortunately due to the poor performance of delegates we ended up in teaching only one simulation over and
over again.
The simulation was delivered to groups of 4-5 delegates and we rotated each person so each had a turn to take
the lead role but we also ensure that we included all members in the discussion. It was very interactive but very
instructor resource intensive. The length of the time allocated to the simulation was 30 minutes and the aim
was for each group to perform an initial rapid A to E assessment and then progressed to a secondary
assessment which would include a focussed examination, interpretation of results and then formulation of a
management plan.
The performance of candidates was so poor that we only got as far as the A to E assessment and never got to
the secondary assessment, interpretation of results and formulating a management plan. In many cases we
only got as far as ‘C’ and in a significant proportion we only got as far as ‘A’. This confirmed to me that there is
a serious issue in the ability of doctors to manage acute medical emergencies. The delegates struggled in
performing a structured assessment and delivering a management plan. The delegates were of all levels from
junior doctors i.e. FY1 through to hospital consultants and GPs. It was not possible to discriminate the level of
the delegate based on their performance as the majority of delegates performed to consistent level, which I am
afraid was poor. It confirmed to me that doctors of all levels desperately need training in acute medical
emergencies simulations as they lack the knowledge and skills.
At the AGM conference apart from performing simulation teaching we also provided practical skills sessions on
Seldinger central venous line cannulation and Seldinger chest drain insertion both under ultrasound guidance.
We also provided access to parts of the interactive virtual learning environment (VLE) on acute medical
emergencies with 4 laptop computer terminals. The sessions were over 2 days and the feedback was very good
(see attached).
One of my aims for SAM was for us to produce a series of educational courses for our members. These included:
1. Management course
2. Acute Medical Emergencies (AME)
3. SCE revision course
So far we have succeeded with the SCE revision course and it has been successful. We have a framework for the
management course but the delivery of this will great deal of work, support and collaboration from others.
With respect to the AME course if was to sit down and write one from scrap I believe that it would be almost
identical to the MedicALS course. I have mapped the MedicALS course to our AIM curriculum (see Attached). As
you can see it maps well to all of the 4 Emergency Presentations, all of the Top Presentations and many of the
Common Competencies.
I know that I proposed SAM supporting the MedicALS course previously but there were concerns re
preferentially supporting one course over another and also concerns re the commercial aspect. In view of my
recent experience at the AGM conference and the fact that trainees have less clinical exposure in their day to
day work; simulation exposure is vital to ensure that they develop the knowledge and skills they require.
MedicALS is run by ALSG which is a charitable organisation (i.e. not for profit) and therefore I do not think that
there is an issue with the commercial aspects. I think that SAM should support and recommend the MedicALS. I
also feel that the SAC for AIM should recommend it for AIM trainees. I gather that the SAC recommends
IMPACT. I have instructed on IMPACT was a member of their writing group and have been a course director,
however, I firmly believe that MedicALS is a superior course and more akin to the needs of our acute internal
medicine trainees.
Where do I feel that MedicALS should fit in with training?
ALERT
Medical Students
ALS
Start of FY1
IMPACT
FY2
MedicALS
CMT2/ACCS3/Start of ST3
MedicALS has been running for more than 10 years. MedicALS is a 3-day course comprising of a flexible oneday on-line component (VLE) and a two-day face-to-face course (see attached factsheet). The 2-day course
consists of two introductory lectures, after which the remaining 2 days of the course is taught through
simulations (see attached programme) and finally ended with a simulation test.
Courses are run regularly at:
 Manchester
 Holland
 Sweden
The total number of candidates trained so far throughout the three centres is 1351.
Other areas where courses have been run:
 West Midlands
 Republic of Ireland
Longterm plan for the course
I would suggest that it is initially recommended but once we get a critical mass of instructors (this will be quite
easily as it would be expected that many of the ST3 trainees will achieve instructors potential) we consider it to
be essential for all AIM trainees. I also think it would be essential for GIM trainees but not sure about pursuing
that but would it have it as recommended for them as well. ALSG do not have a problem with running courses
in other regions with support.
I hope that this letter explains my thoughts clearly. I am happy to clarify and other points.
I have in enclosed:
 MedicALS factsheet
 MedicALS 2-day programme
 Example simulations
 Feedback from the AGM conference
 Mapping of the MedicALS course to the AIM curriculum
 Promotional video:
o https://vimeo.com/113950346
o Password: alsg2014
Yours sincerely
Philip Dyer
APPENDIX 2
Mapping Between MedicALS Course and AIM 2009 curriculum (Amended 2012)
COMMON COMPETENCIES
History Taking
Course - All simulations
Manual - Chapter 3. A structured approach to medical emergencies
VLE - Topic 2: Structured approach to medical emergencies
Clinical Examination
Course - All simulations
Manual - Chapter 3. A structured approach to medical emergencies
VLE - Top to toe examination
Therapeutic and safe prescribing
Manual - Part VIII. Appendix Drugs commonly used in the management of medical
emergencies
VLE - Topic 16: Fluids and electrolytes
Time management and decision making
Course - All simulations
Manual - Chapter 3. A structured approach to medical emergencies
Manual - Part VI. Interpretation of Emergency Investigations
 Chapter 26. Acid-base balance and blood gas analysis
 Chapter 27. Dysrhythmia recognition
 Chapter 28. Chest X-ray interpretation
 Chapter 29. Haematological investigations
 Chapter 30. Biochemical investigations
 VLE - Topic 11: Blood gas interpretation
 VLE - Topic 17: Blood tests
Decision making and clinical reasoning
Course - All simulations
Manual - Chapter 3. A structured approach to medical emergencies
VLE - Data Interpretation Paper
VLE - MedicALS pre course MCQ
The patient as central focus of care
Course - All simulations
Manual - Chapter 3. A structured approach to medical emergencies
VLE - Topic 2: Structured approach to medical emergencies
Prioritisation of patient safety in clinical practice
Course - All simulations
VLE - Topic 2: Structured approach to medical emergencies
Team work and patient safety
Course - All simulations
VLE - Topic 2: Structured approach to medical emergencies
Communication with colleagues and cooperation
Course - All simulations
Evidence and guidelines
Manual – All sections
Teaching and training
Course - All simulations
Personal behaviour
Course - All simulations
Relationships with patients and communication within a consultation
Course - All simulations
Infection control
Course - All simulations
COMMON COMPETENCIES PROBABLY NOT MAPPED TO MEDICALS
 Principles of quality and safety improvement
 Managing long term conditions and promoting patient self-care
 Breaking Bad news
 Complains and medical error
 Health Promotion and public health
 Principles of medical ethics and confidentiality
 Valid Consent
 Legal frame work for practice
 Ethical research
 Audit
 Management and NHS Structure
EMERGENCY PRESENTATION
Shocked Patient
Manual - Chapter 9. The patient with shock
VLE - Topic 4: The shocked patient
VLE - Topic 10: Inotropes
Unconscious patient
Manual - Chapter 11. The patient with altered conscious level
Course - Simulations airway and breathing
Anaphylaxis
Manual - Chapter 9. The patient with shock
Course – Simulations circulation
VLE - Topic 4: The shocked patient
Cardio-Respiratory Arrest – Not mapped
THE TOP PRESENTATIONS
Abdominal Pain
Course – Total assessment – abdominal pain
Manual - Chapter 15. The patient with abdominal pain
AKI and CKD
Manual – Chapter 20. Organ Failure
Breathlessness
Course – Total assessment Pulmonary oedema secondary to infective endocarditis
Manual - Chapter 15. The patient with breathing difficulties
VLE -Topic 3: The breathless patient
VLE - Topic 11: Blood gas interpretation
Chest Pain
Manual - Chapter 10. The patient with chest pain
Course – Simulations circulation
Confusion/ Acute Delirium
Manual - Chapter 19. The patient with acute confusion
Manual – The elderly patient
Simulations disability and exposure
Diarrhea
Manual - Chapter 15. The patient with abdominal pain
Fever
Course – Total assessment Pulmonary oedema secondary to infective endocarditis
Manual - Chapter 24. The immunocompromised patient
VLE - Topic 15: Pyrexia
Fits and seizures
Manual - Chapter 11. The patient with altered conscious level
VLE - Topic 13: The collapsed patient
Haematemsis and Melaena
Manual - Chapter 15. The patient with abdominal pain
Headache
Manual Chapter 14. The patient with headache
VLE - Topic 14: Headache
Jaundice
Manual - Chapter 15. The patient with abdominal pain
Palpitations
Manual - Chapter 12. The collapsed patient
VLE - Topic 6: Peri-arrest rhythm recognition
Poisoning
Manual - Chapter 13. The overdose patient
VLE - Topic 12: The poisoned patient
Acute Back Pain
Manual - Chapter 25. The patient with acute spinal cord compression
Blackout/Collapse
Manual - Chapter 11. The patient with altered conscious level
Limb pain and swelling
Manual - Chapter 16. The patient with hot red legs or cold white legs
Manual - Chapter 17. The patient with hot and/or swollen joints
Rash
Manual - Chapter 18. The patient with a rash
Weakness and Paralysis
Manual - Chapter 25. The patient with acute spinal cord compression
Top Presentations not mapped
 Management of patient requiring palliative and end of life care
 Falls
PROCEDURAL COMPETENCE FOR AIM
Central venous cannulation by IJ or femoral.
Manual - Chapter 32. Practical procedures: circulation
DC Cardioversion
Manual - Chapter 32. Practical procedures: circulation
ICD Insertion for Pneumothorax
Manual - Chapter 31. Practical procedures: airway and breathing
Arterial Line insertion
Manual - Chapter 31. Practical procedures: airway and breathing
Temporary cardiac pacing via transvenous route.
Manual - Chapter 32. Practical procedures: circulation
ICD insertion using saldinger technique with U/S guidance.
Manual - Chapter 31. Practical procedures: airway and breathing
Procedural competencies not mapped
 Knee Aspiration
 Sangstaken Blakemore tube insertion.
 Abdominal Paracentesis
APPENDIX 3
MedicALS Programme
Day One
08.30 – 09.00 Faculty meeting
09.00 – 09.15 Introduction and welcome [ ]
09.15 – 10.15
Structured approach to medical emergencies including demonstration
[]
10.15 – 13.30
Simulations airway and breathing (including 15 minutes for coffee at
11.15)
10.15 –
11.15
11.30 –
12.30
Airway 1
Breathing 1
1
A
D
C
2
B
A
D
3
C
B
A
4
D
C
B
Faculty
12.30 – 13.30
Airway 2
Breathing
2
13.30 – 14.30
LUNCH including 30 minute surgery for candidates to raise questions
with instructors
14.30 – 16.00
Simulations circulation
Faculty
14.30 – 15.00
15.00 – 15.30
15.30 – 16.00
Circulation 1
Circulation 2
Circulation 3
1
A
D
C
2
B
A
D
3
C
B
A
4
D
C
B
16.15 – 16.55
16.55 – 17.35
17.35 – 18.15
D&E
1
D&E
3
D&E
5
16.00 – 16.15
COFFEE
16.15 – 18.15
Simulations disability and exposure
Faculty
D&E
2
D&E 4
D&E 6
1
A
D
C
2
B
A
D
3
C
B
A
4
D
C
B
18.15 – 18.45 Secondary assessment demonstration [ ]
Day One continued
18.45 – 19.00 Summary of the day [ ]
19.00 – 19.30
Faculty meeting
Day Two
08.00 – 08.30
Surgery for candidates to raise questions with instructors
08.30 – 12.15
coffee at 10.30)
Simulations secondary assessment (including 15 minutes for
Faculty
08.30 –
09.30 – 10.30
10.45 – 11.45
11.45 –
09.30
D&E
1
D&E
2
12.15
D&E
3
D&E
4
D&E
5
D&E 6
“The Don’t
Know”
1
A
D
C
B
2
B
A
D
C
3
C
B
A
D
4
D
C
B
A
12.15 – 12.45
LUNCH
12.45 – 15.45
Simulations total assessment
Faculty
12.45 – 13.45
Total
1
Total 2
13.45 – 14.45
Total 3
Total 4
14.45 – 15.45
Total
5
Total
6
1
A
D
C
2
B
A
D
3
C
B
A
4
D
C
B
15.45 – 16.00 COFFEE
Day Two continued
16.00 – 18.00 Simulation test
Station
1
2
3
4
16.00 – 16.20
1
7
13
19
16.20 – 16.40
2
8
14
20
16.40 – 17.00
3
9
15
21
17.00 – 17.20
4
10
16
22
17.20 – 17.40
5
11
17
23
17.40 – 18.00
6
12
18
24
Faculty
18.00 – 18.30 COFFEE and faculty meeting
18.30 – 18.45 Candidate feedback