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Research Article *Corresponding author Mariam Mostafa Al-Werdani, Mansoura School of medicine, Mansoura University, AlGomhoria St., Basic Life Support Knowledge Mansoura, Al Daqahlia, Egypt, Tel: +201019044121, Email: Submitted: 23 September 2018 of Medical Students: A Single Accepted: 12 November 2018 Published: 13 November 2018 ISSN: 2476-2016 Faculty Study in Egypt Copyright Mariam Mostafa Al-Werdani1*, Abdalrhman Mostafa Mokhtar1, © 2018 Al-Werdani et al. Ahmed Khaled Ebead1, Enas El-Sherbeny2, Abdel-Hady El- OPEN ACCESS Gilany2 Keywords 1Mansoura School of Medicine, Mansoura University, Egypt. • Basic life support; Cardiopulmonary resuscitation; 2Department of Public Health, Mansoura School of Medicine, Egypt Medical education; First aid
Abstract Aim of the study: To measure the levels of Basic Life Support (BLS) knowledge in medical students, Mansoura University, Egypt. Methods: Our cross-sectional study was carried out in Mansoura School of Medicine, Mansoura University, Egypt. Only Egyptian medical students from the subject-based learning system were allowed to participate. Using a self-reported questionnaire, we measured the number of students with good BLS knowledge, attending BLS courses, self-perceived ability to handle emergency situations, previous exposure to emergency situations, and the number of students wanting to learn more about BLS as a part of their curriculum. Results: With a response rate of 85%, only 5% of the participants scored 50% or more in the questionnaire. Using a cut-off point of 8 (added 1 SD to the mean BLS knowledge score), clinical students were 2.2 times (95% CI: 1.5 -3.1) more likely to achieve good BLS knowledge scores than preclinical students. Attending BLS courses, self-perceived ability to manage emergency situations, and being male were all independent predictors of good BLS knowledge scores, with adjusted Odd’s ratios of 1.7 (95% CI: 1.2-2.4), 2 (95% CI: 1.2-3.3), and 1.8 (95% CI: 1.3-2.6) respectively. Ninety-six percent of the study participants wanted to learn more about BLS as a part of their curriculum. Conclusions: Ninety-five percent of the students achieved poor BLS knowledge scores. Revisiting the BLS teaching strategies in the subject based system is strongly encouraged. We advise medical students to take BLS courses to raise their knowledge levels.
ABBREVIATIONS [7], which makes BLS knowledge and training essential for the BLS: Basic Life Support; PS: Preclinical Students; CS: Clinical perform BLS skills perfectly. Unfortunately, the literature shows Students public, not just for the medical personnel who are expected to INTRODUCTION theprevalent current poor medical BLS education knowledge systems. among medical students and Basic life support (BLS) is a set of skills that are essential to junior doctors [8–14], which indicates a defect in BLS teaching in In Egypt, Mansoura School of Medicine has two teaching of emergency patients, especially those suffering from cardiac arrest,the general stroke public, and foreign as they body significantly airway obstruction raise the [1]. survival This is ratedue systems: subject-based and problem based, with the subject- based being the main one. It consists of three Pre-clinical years to their efficiency in increasing survival following out of hospital (students are taught academic subjects), 3 clinical years (clinical cardiacIn the arrest East until Mediterranean expert medical Region help arrives (EMR), [2,3]. ischemic heart ofsubjects), other departments’ and one year of curricula internship. i.e. Pediatrics,BLS teaching Toxicology is distributed and Internalthroughout medicine. the clinical Students years arenot asalso a separateintroduced subject to some but asminor part disease is the leading cause of death causing 20.3% of total aspects of BLS in their preclinical years. mortalities in the EMR, while deaths from road traffic accidents attribute to 3.1% of total mortality (across all age groups in both To the best of the authors’ knowledge, there are scarce data about BLS knowledge of medical students in Egypt. This (CPR)sexes), is further highly recommended emphasizing theand importanceconsidered as of the BLS most in savinguseful those lives [4,5]. Immediate Cardiopulmonary Resuscitation prompted us to study the BLS knowledge of Egyptian medical students and its associated factors, comparing the knowledge arrest [6], so the recent guidelines of the European Resuscitation of Clinical students (CS) to their preclinical peers (Preclinical Councilpreventive (ERC) measure highlight against the cerebral critical injury role of after bystander sudden cardiac CPR in Students: PS). increasing survival rate of patients with sudden cardiac arrest Cite this article: Al-Werdani MM, Mokhtar AM, Ebead AK, El-Sherbeny E, El-Gilany AH (2018) Basic Life Support Knowledge of Medical Students: A Single Faculty Study in Egypt. Arch Emerg Med Crit Care 3(2): 1044. Al-Werdani et al. (2018) Email: [email protected]
Central Bringing Excellence in Open Access METHODS breathing, circulation) in unresponsive victims and techniques of removing foreign body in choking Location and duration: This study was conducted among emergencies. medical students of Mansoura University, Mansoura, Al Dakahlia, Egypt from December 2017 to February 2018. 3- CPR Techniques in different age groups. Study design: a cross sectional study followed by a - Part three consisted of 9 questions structured to simulate comparative study. real life emergency situations. Sample size and inclusion criteria: According to the Statistical analysis: after excluding the incomplete response department of students’ affairs, the total number of students in forms, the data were analyzed on 664 responders with a response Mansoura medical school in 2016 was 6783 students: 3481 in the rate of 85%. The results were analyzed using key answers based preclinical years and 3302 in the clinical years. The sample size on the recent guidelines of the ERC [15]. was calculated using epi info program assuming that the expected The data were statistically analyzed using Statistical Package frequency of BLS knowledge is 50% the least required sample for Social Sciences program (SPSS v24) – IBM company, New size was 364 this was multiplied by two to compensate for the York, United States. Each question was scored (0, 1) with 1 for a design effect of the cluster sampling method. The students were correct answer and 0 for an incorrect answer. We used a cut off value (mean BLS knowledge +1 SD =8) to divide the students into allocation. Participants had to be Egyptian students studying at 2 groups of good and poor BLS knowledge. We decided to use 8 selected through stratified cluster sampling with proportional the subject-based system.We recruited students from the subject as a cut-off point to facilitate better comparisons across the study based system due to the following: participants (since the BLS knowledge scores were abysmally 1. The other system’s students were inaccessible to us. low). There was no gold standard approach available to the (main reason) authors to study BLS knowledge and determine the optimum cut- off point for the questionnaire. 2. Students from the Problem Based System (PBL) receive quality education, and a threemonth-emergency medicine Multivariate logistic regression analyses were used to identify course. independent variables associated with good BLS knowledge.
3. Subject-based system is the main system in the school. item of the questionnaire was compared between preclinical 4. Subject-based system students are more likely to continue andAdjust clinical Odds ratio students at 95% using confidence Pearson’s interval chi square was calculated. test. The Each total working in Egypt. score was then compared across the participant characteristics using the Independent sample t-test. P value less than 0.05 was Data collection: ethical approval was obtained from the Institutional Review Board (IRB) of Mansoura faculty of medicine. During class time, data were collected using an anonymous consideredRESULTS statistically significant. self-administered structured questionnaire in English. An A total of 662 students participated in the study, of informed written consent was obtained from all students before participation; the collector informed them about aim of study and students scored more than 50% in the questionnaire. Table (1) describeswhom383 the were percentage PS, and 279of students were CS. achieving Only five good percent knowledge of the of this research only. The questionnaire was structured after extensivethat all collected literature data review will be to confidentially collect relevant used data. for theIt was purpose used previously to assess BLS knowledge among Indian students [9]. malescores students in each achieving study group. good We knowledge encountered scores. some There significant was no gender differences, with a significantly higher percentage of clinical knowledge. The key answers of the questionnaire were We modified the order of questions to start with theoretical then emergency situations compared to those who have not. significant difference between students who have been through experts. (S1,2) In addition, a logistic regression was performed to ascertain modified based on the opinion of public health and emergency the effects of Academic year, Sex, BLS training course and Self- The structured questionnaire consisted of 3 parts: perceived ability to manage emergency situation (Table 2). The - Part onehad questions about the following variables: Taking previous BLS training courses, the students’ self- < 0.0005, explaining 21.0% (Nagelkerke R2) of the variance in BLS perceived ability to manage emergency situations and logistic regression model was statistically significant, χ2 =16.8, p their willingness to learn more about BLS as part of the times more likely to have good BLS knowledge than PS. Attending curriculum. BLSknowledge, training and courses, correctly thinking classified they 69.3% can of manage cases. CS emergency were 2.2 situations, and being male were independent predictors of good - Part two consisted of 11 questions to assess BLS BLS knowledge. theoretical knowledge.Thesecovered the following aspects of BLS: Table (3) shows the 20-item-questionnaire, scanning for 1- The abbreviation of BLS, AED (Automated External 3significant and 7, which differences asked about between the location the answers of chest of compressions PS and CS. Interestingly, PS performed significantly better in questions 2- Defibrillator)Sequential steps and EMS of (Emergency BLS (Checking Medical for Service). airway, in infants and their depth in children over one year while CS
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Table 1: Good BLS knowledge and its associated factors % in the Good knowledge column represents the % of students in the Total column with good BLS knowledge while the % in the Total column represents the % of students out of the total number of participants(662). Total (662) Good knowledge (225) Variable X2 P value N (%) N (%) Sex Male 209 (31.6) 90 (43.1) 11.2 0.001 Female 453 (68.4) 135 (29.8) Attending BLS training course Yes 246 (37.2) 112 (45.5) 23.2 <0.001 No 416 (62.8) 113 (27.2) Academic year Preclinical 383 (57.9) 101 (26.4) 23.5 <0.001 Clinical 279 (42.1) 124 (44.4) Exposure to emergency situation Yes 208 (31.4) 80 (38.5) 2.7 0.1 No 454 (68.6) 145 (31.9) Self-percieved ability to manage emergency situations Yes 88 (13.3) 46 (52.3) 15.1 <0.001 No 574 (86.7) 179 (31.2) Students wanting to learn more about BLS as a part of their curriculum Yes 641 (96.8) 215 (33.5) 1.7 0.18 No 21 (3.2) 10 (47.6)
Table 2: Multivariate logistic regression of independent predictors of good BLS knowledge. Predictor β P value AOR (95% CI) Academic year Clinical 0.79 2.2(1.5 -3.1) < 0.001 Pre-clinical ---- r Self-perceived ability to manage emergency situations Yes 0.7 2 (1.2 -3.3) 0.004 No ---- r Sex Male 0.62 1.8(1.3 – 2.6) 0.001 Female --- r BLS training course Yes 0.54 1.7 (1.2 –2.4) 0.003 No ---- R Constant % predicted = 69.3%, Model c2 = 16.8, P = 0.005
Table 3: comparisons between clinical and preclinical students regarding items and total score of BLS knowledge. Preclinical Clinical (279) Question - no. (%) (383) P value N (%) N (%) What Does "BLS" stand for? 243 (63.4) 238 (85.3) <0.001 What is the location for chest compression? 157 (41) 124 (44.4) 0.38 What is the location for chest compression in infant? 102 (26.6) 50 (17.9) 0.009 Depth of compression in adults during CPR. 149 (38.9) 105 (37.6) 0.74 Depth of the compression in children over 1 year during CPR. 48 (12.5) 20 (7.2) 0.03 Depth of compression in infant during CPR. 45 (11.7) 16 (5.7) 0.08
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Rate of chest compression in adult and children during CPR. 96 (25.1) 106 (38) <0.001 In adult, compression ventilation ratio of CPR (If single rescuer). 137 (35.8) 134 (48) 0.002 In pediatric, compression ventilation ratio of CPR (If single rescuer). 80 (20.9) 66 (23.7) 0.4 What does "AED" stand for? 51 (13.3) 28 (10) 0.2 What does "EMS" stand for? 172 (44.9) 162 (58.1) 0.001
152 (39.7) 166 (59.5) <0.001 response? (Note: You are alone there). When you find someone unresponsive in the middle of the road, what will be your first 206 (53.8) 180 (64.5) 0.006 what will be your immediate action? If you confirm somebody is not responding to you even after shaking and shouting at him, How do you give rescue breathing in infants? 86 (22.5) 112 (40.1) <0.001 If you and your friend are having food in a canteen and suddenly your friend starts expressing 101 (26.4) 101 (36.2) 0.007
You are witnessing an infant who suddenly started choking while he was playing with the toy, symptoms of choking, what will be your first response? 50 (13.1) 71 (25.4) <0.001 You are witnessing an adult unresponsive victim who has been submerged in fresh water and you have confirmed that he is unable to cry (or) cough, what will be your first response. 62 (16.2) 58 (20.8) 0.13 step? Youjust removednoticed that from your it. He colleague has spontaneous has suddenly breathing, developed but slurringhe is unresponsive. of speech and What weakness is the first of 91 (23.8) 92 (33) 0.009 right upper limb. Which one of the following can be done? A 50-year-old gentleman with retrosternal chest discomfort, profuse sweating and vomiting. 101 (26.4) 73 (26.2) 0.95 What is next? If you do not want to give mouth-to-mouth CPR the following can be done EXCEPT? 168 (43.9) 121 (43.4) 0.9 Mean Score ± S.D. 5.9 ± 2.5 7.25 ± 2.5 < 0.001 %: the percentage of correct answers out of the total number of preclinical/clinical students performed in questions number 11-20 which were designed to simulate real life situations. comparativestudy found study an association showed better between BLS goodknowledge first aid scores knowledge among DISCUSSION formallyand taking trained first aid versus courses, untrained especially medical formal students ones [14]. [17]. Another Some To our disappointment, only 5% of the participants scored more than 50% in the questionnaire. This goes in line with other between previous training and good BLS knowledge [8,13]. studies performed on medical students in the literature, which Thisstudies, difference however, in results showed might that be there due isto nothe significantconfounding relation effect showed slightly better levels of good knowledge of 17%, and 19% of the time spent after training without rehearsal. Avisar et al. in Pakistan and Netherlands respectively [9,12]. comparing a 1-year-post-training group to a 2-year-post-training oneshowed [18]. that That retention goes to showof CPR that skills the goes continuous down significantly rehearsal of when BLS than their female counterparts. Being male was even considered skills is quite important. an independentSurprisingly, predictor however, of males BLS knowledge scored significantly according to better our regression model. This goes against previous literature that studied BLS knowledge in medical students or even in junior knowledge scores between CS and PS. This goes in accordance doctors [11,14]. The gender inequality index (GII) in Egypt, Saudi withStating CS receiving the obvious, BLS courses there wasas part a significant of their curriculum difference asin wellBLS Arabia, and Pakistan during the time of our and the referenced as having better clinical awareness overall. Similarly, previous studies were 0.449 (2017), 0.234 (2017), and 0.575 (2010) [16]. studies revealed better BLS knowledge among senior medical This suggests that the male female differences in BLS knowledge attainment are not explained by gender inequality since Saudi questions 4 and 7, which asked about chest compression location Arabia, with its astonishingly low GII of 0.234, had their females andstudents depth [13,19]. in infants, PS despite showed not significantly taking any higher pediatric scores rounds on achieve better BLS knowledge scores than males. Pakistan had whatsoever. This could be attributed to self-interests of students females achieving higher than males as well, despite their high GII or extra-curricular activities related to pediatrics. Moreover, of 0.575. Egypt, being the one in between (GII: 0.449), had higher male BLS scores than females. There are a lot of uncontrolled designed to simulate real life situations. This goes to show that variables coming with this suggestion however, so more research CS have scored developed significantly realistic better clinical in questions awareness 12-20, compared which to weretheir should be done to delineate the effect of gender inequality on BLS preclinical peers. knowledge attainment across countries. BLS knowledge and previous exposure to emergency situations. of students with good knowledge scores, our regression model However,Our findings self-perceived showed noability significant to manage association emergency between situations good showedAttending that it BLSeven courses works as significantly an independent increased predictor the number of BLS knowledge. This is consistent with the literature; a previous and the regression model. One possible explanation of this is was significant in both the association with good BLS knowledge,
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Central Bringing Excellence in Open Access the confounding effect of whether the student was prepared or Resuscitation and Emergency Cardiovascular Care. Part 1: not when facing emergency situations i.e.: If the student was Introduction. Circulation. 2005; 112(22 SUPPL.). not prepared with good knowledge and skills, the emergency 2. Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen situation may have traumatized the student, which affected his/ EF, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival of a previous study conducted in France that found a positive after out-of-hospital cardiac arrest. Jama. 2013; 310: 1377-1384. her self-confidence. This explanation ties in with the findings association between the number of exposure to cardiac arrest 3. Pollack R, Brown S, Rea T, Aufderheide T, Barbic D,Buick JE, et al.Impact
Functional Outcomes in Shockable Observed Public Cardiac Arrests. eventsIn this and study,self-confidence 96% of students regarding said BLS they skills need [20]. to know more Circulation.of Bystander 2018; Automated 137: 2104-2113 External . Defibrillator Use on Survival and about BLS, and stated their willingness to learn more about it as part of their curriculum. This falls in line with many studies in 4. World Health Organization. WORLD HEALTH STATISTICS - MONITORING HEALTH FOR THE SDGs. World Heal Organ 2016:1.121. the literature, including a study conducted on American students where 64.2% thought that BLS should be included in their 5. Summary tables of mortality estimates by cause, age and sex, globally curriculum [8,14,21]. and by region, 2000–2016. WHO. As for the limitations of this study, we only assessed the 6. Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K, et al. Bystander Efforts and 1-Year Outcomes in theoretical BLS knowledge using a self-reported questionnaire. Out-of-Hospital Cardiac Arrest. N Engl J Med. 2017; 376: 1737–1747. We did not assess the practical BLS knowledge. Another general limitation of all self-reporting studies is the dependence on 7. response to, In mountain and rural areas all CPR providers should self-perception and lack of objectivity. In this study, such performPerkins GD,chest Soar compressions J, Monsieurs and KG, rescue Nolan breaths J. Guidelines for patients 2017 in update : cardiac variables include self-perceived ability to manage emergency arrest: Pharmacotherapy during cardiac arrest-When evidence-based data failed to be implemente. Resuscitation 2018; 0. 8. Joseph N, Kumar GS, Babu YPR, Nelliyanil M, Bhaskaran U. 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Cite this article Al-Werdani MM, Mokhtar AM, Ebead AK, El-Sherbeny E, El-Gilany AH (2018) Basic Life Support Knowledge of Medical Students: A Single Faculty Study in Egypt. Arch Emerg Med Crit Care 3(2): 1044.
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