What's Inside (16 Slides)

• Miller's Anesthesia, 10e (Chapter 41 & 42)
• Barash, Cullen & Stoelting's Clinical Anesthesia, 9e (Chapter 35)
• Morgan & Mikhail's Clinical Anesthesiology, 7e (Chapter 45)
• ASRA Guidelines 4th Edition - Horlocker TT et al., Reg Anesth Pain Med 2018

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Teaching Final Year MBBS Students: Emergency Procedures During Pandemics, Role Plays, and Debriefing

Under NMC CBME Framework (GMER 2023 / Pandemic Module + AETCOM)

1. REGULATORY FRAMEWORK - What NMC Mandates

2. SESSION PLANNING - Emergency Procedures During Pandemics

A. Learning Objectives (Competency-Based)

1. Know (K) - Describe the chain of command during a pandemic surge, triage principles (START/SALT), and pandemic-specific emergency protocols (airway in COVID, isolation precautions in Ebola, etc.)
2. Skill (S) - Demonstrate donning/doffing PPE, perform HHGE (high-high guard entry) procedures, document outbreak notification correctly
3. Attitude (A) - Show professionalism under resource-limited conditions, communicate transparently with patients and families

B. Session Structure (3-Hour Block - NMC SGL + Skills Lab Format)

Hour 1 - Interactive Lecture / Trigger Scenario (30 min lecture + 30 min trigger)

"It is Day 3 of a declared pandemic. Your district hospital ED has 3 ventilators for 40 critically ill patients. You are the duty doctor. A 65-year-old man with respiratory failure arrives. His SpO2 is 78%. The ward is full. The hospital has run out of N95 masks. The patient's son is aggressive. The hospital nurse asks you to document 'patient refused ventilator' to protect the hospital. You have not spoken to the patient yet."

• Pandemic triage principles (utilitarian vs. egalitarian ethics)
• Crisis Standards of Care - WHO/NITI Aayog framework
• Epidemic Diseases Act, Disaster Management Act - legal powers and duties of a doctor
• PPE protocols - correct donning and doffing sequence
• ISBAR communication (Identification, Situation, Background, Assessment, Recommendation)

Hour 2 - Skills Station Rotation (3 stations × 20 minutes each)

Hour 3 - Role Plays + Debriefing (see sections 3 and 4 below)

3. ROLE PLAYS FOR COMMUNICATION SKILLS AND DOCUMENTATION

A. NMC AETCOM Framework for Role Plays

1. Introductory small group - introduce principles (empathy, structured history, informed consent)
2. Focused small group with role play - observe, critique, and discuss mistakes
3. Skills lab - perform on standardized patient with self-critique + facilitator critique

B. Four Core Role Play Scenarios

Scenario 1 - Breaking Bad News During a Pandemic (SPIKES Protocol)

• Roles: Doctor (student), Patient's family member (student), Observer (student with checklist)
• Situation: Informing a family that their COVID-positive elderly mother has died and the body cannot be released for traditional last rites per pandemic protocols
• Skills targeted: Empathy, delivering difficult news, explaining legal/cultural constraints without dismissiveness
• Documentation task: Write the death summary noting pandemic protocol compliance

Scenario 2 - Obtaining Informed Consent Under Pressure

• Roles: Doctor, Frightened patient, Aggressive relative
• Situation: Obtaining consent for intubation in a resource-limited surge when the patient partially understands but the family is refusing
• Skills targeted: Explaining prognosis honestly, documenting refusal vs. consent correctly, medico-legal protection
• Documentation task: Write a consent note that is legally defensible

Scenario 3 - ISBAR Handover During Surge

• Roles: Outgoing duty doctor, Incoming duty doctor
• Situation: Handing over 12 pandemic patients at shift change; 2 are critical, 1 has a pending medico-legal issue, drug shortage noted
• Skills targeted: Structured, concise, complete handover - no omissions
• Documentation task: Complete a written ISBAR handover form

Scenario 4 - Communicating with a Vaccine-Hesitant Patient

• Roles: Doctor, Vaccine-hesitant patient with misconceptions from social media
• Situation: Pre-vaccination counselling during a pandemic vaccination drive
• Skills targeted: Non-judgmental communication, motivational interviewing, countering misinformation with evidence
• Documentation task: Write a vaccination counselling note in the OPD record

C. Role Play Conduct - Step-by-Step

D. Documentation Skills - What to Teach Specifically

1. Pandemic Notification Form - Notifiable diseases to the CMO under Epidemic Diseases Act 1897 (amended 2020)
2. Death Certificate (Form 4A) - with cause of death hierarchy; pandemic-related deaths and correct ICD-10 coding (U07.1 for COVID-19)
3. Medico-legal documentation - when to call police, how to document injuries in a pandemic context
4. Consent documentation - differentiating valid consent, implied consent, and emergency doctrine
5. Discharge summary during surge - brief but complete; SBAR format
6. Isolation order documentation - legal authority, duration, rights of the patient

4. DEBRIEFING AND FEEDBACK

A. Why Debriefing Is the Most Important Step

B. The GAS Model of Debriefing (Gather-Analyze-Summarize)

Phase 1 - GATHER (3-4 minutes)

• "How did that feel?"
• "Doctor - what were you thinking at that moment?"
• "Patient - did the doctor make you feel heard?"
• Do NOT correct or teach yet. Just listen. This reduces defensiveness.

Phase 2 - ANALYZE (8-10 minutes)

• State what you observed (advocacy): "I noticed you avoided direct eye contact when the family became aggressive..."
• Ask why (inquiry): "...what was going through your mind at that point?"
• This is non-judgmental and opens genuine reflection

• What went well? (Always start positive)
• What was the most difficult moment and why?
• What would you do differently?
• How does what you did compare to the SPIKES / ISBAR framework?
• What are the medico-legal implications of how you documented this?

Phase 3 - SUMMARIZE (2-3 minutes)

• Facilitator synthesizes 2-3 key learning points
• Students write their own "take-home" learning point (one sentence each)
• Bridge to next session: "Next time you're in Medicine OPD, practice this with a real patient"

C. Feedback - Formative vs. Summative

D. PENDLETON'S Feedback Model (NMC AETCOM Recommended)

1. Student speaks first: "What do you think went well?"
2. Observer/peer adds: "What else went well?"
3. Student identifies improvement: "What would you do differently?"
4. Facilitator adds improvement areas: (now the teacher corrects - but last)
5. Summary: Brief positive close

E. Structured Observation Checklist (Sample - Scenario 1: Breaking Bad News)

5. ASSESSMENT - NMC-Aligned

6. PRACTICAL TIPS FOR THE TEACHER

1. Group size: 8-10 students per facilitator is ideal for role plays; larger classes need multiple facilitators running parallel groups
2. Rotate roles: Every student must play the "doctor" role at least once - observers learn, but doing is essential
3. Scenario cards: Write separate cards for doctor and patient with different information - the "hidden information" gap drives authentic communication
4. Psychological safety: Explicitly state at the start - "There are no right/wrong answers; this is a safe space to make mistakes"
5. Video recording (optional): Recording role plays (with consent) and reviewing together significantly improves learning - validated in NMC AETCOM research
6. Avoid over-correction: Do not stop the role play to correct unless it is a critical error - interruptions destroy the learning moment
7. Link to NExT: Frame all sessions around NExT competencies - final year students are highly motivated by exam relevance

Key References

• NMC CBME Curriculum Guidelines 2023 (effective August 1, 2023) - Pandemic Module: 28 hours in Final MBBS
• NMC AETCOM Module - Role Play Framework, Structured Feedback, Communication Competencies
• Epidemic Diseases Act 1897 (amended 2020) and Disaster Management Act 2005 - legal framework for pandemic documentation
• WHO Crisis Standards of Care - Triage during surge
• GAS Debriefing Model - Fanning RM, Gaba DM. Simulation in Healthcare 2007
• PENDLETON'S Feedback Model - Pendleton D, et al. The Consultation: An Approach to Learning and Teaching. Oxford, 1984
• SPIKES Protocol - Baile WF, et al. The Oncologist 2000;5:302-311

ROLE-PLAY SCENARIO CARDS

Final Year MBBS | Pandemic Module + AETCOM | NMC CBME

Instructions for all cards: Read ONLY your own card. Do NOT show it to the other participant. Stay in character throughout the role play. Step out of role only when the facilitator gives the STOP cue.

SCENARIO 1 - Breaking Bad News During a Pandemic

🟦 CARD 1A - DOCTOR'S CARD

• Mrs. Kamla Devi died at 14:35 hrs. Cause: Respiratory failure secondary to COVID-19 pneumonia
• Per State Government pandemic protocol (Circular No. CMO/2020/114), the body must be wrapped in a leak-proof bag and handed over within 4 hours. No open viewing of the face. No traditional bathing of the body. Cremation/burial within 12 hours
• The family is waiting in the relatives' room outside the ward. There are 3 family members: her son (Rajesh, ~40 yrs), her daughter-in-law, and a younger woman (possibly another daughter)
• You have never met this family before. The last clinical update was given by your colleague yesterday

• Break the news of the death clearly and compassionately
• Explain the pandemic protocol for the body - the family cannot see the body as they normally would
• Document the conversation in the case notes afterward (write this during or just after the role play)

🟥 CARD 1B - FAMILY MEMBER'S CARD (Son - Rajesh)

• You travelled from Mumbai (8 hours by train) as soon as your mother was admitted. You arrived last night
• You last spoke to a nurse this morning at 10 AM and were told your mother was "stable but critical"
• You are exhausted, frightened, and have not eaten since morning
• Your wife (Sunita) and younger sister (Meena) are with you

• You know your mother is very ill but you are not prepared for her death. You are still hoping she will recover
• You are anxious because you have not been allowed inside the ward at all - "they won't even let us see her"
• You are deeply religious. In your family tradition, the eldest son must be present at the moment of death, must see the face, and must perform the last rites with the body bathed and dressed

• You are initially silent and in shock. Then you start crying. Ask: "When? Why didn't anyone call us sooner?"

• You become upset and resistant: "This is wrong. She is my mother. I have the right to see her face. Who gave you the right to take this from me? I will go to the court."
• After some resistance, if the doctor is empathetic and explains clearly (not dismissively), you gradually become quieter and more accepting, though still very sad
• You ask: "Can I at least see her through the glass? Even for one minute?"
• You ask: "Who will give me her belongings? She had a gold chain."

SCENARIO 2 - Obtaining Informed Consent Under Pressure

🟦 CARD 2A - DOCTOR'S CARD

• Mr. Gupta has a reasonable chance of survival with ventilation but prognosis is guarded (~40-50% ICU mortality in your facility currently)
• Without ventilation, he will likely die within 1-2 hours
• You need his consent (or family's if he lacks capacity) to intubate
• Hospital's pandemic legal cell has advised: document all consents carefully; a verbal consent with a witness is valid if written consent cannot be obtained in time
• The son has already told the nurse, "Do everything, doctor" but the wife seems hesitant

• Assess Mr. Gupta's capacity briefly (can he understand and communicate a choice?)
• Explain the procedure, its purpose, risks (sedation, possible prolonged ventilation, ICU stay), and alternatives (death without intubation)
• Obtain consent - from patient if capacitous, or family if not
• Handle the disagreement between family members
• Document the consent discussion in the notes (write this during/after the role play)

🟥 CARD 2B - PATIENT AND FAMILY CARD

• You are very breathless and frightened. Speaking more than 3-4 words is exhausting
• You understand what is happening to you. You are scared of "that machine" (ventilator)
• If the doctor speaks slowly, clearly, and gives you time - you CAN nod yes or no
• Your hidden information: 6 months ago, when your brother-in-law was on a ventilator for 3 months and never woke up, you told your wife, "If that ever happens to me, don't put me on those machines." You have NOT written this down anywhere
• If the doctor asks you directly: "Mr. Gupta, do you want us to put you on the breathing machine to help you?" - you look at your wife, hesitate, then nod weakly - you are too frightened to refuse but you are not fully willing either
• You cannot speak in full sentences. Use gestures, nods, single words only

• You are terrified of losing your husband. You love him and want him to survive
• BUT you remember very clearly what Harish said after his brother-in-law died: "Never put me on those machines, Sunita. Let me go peacefully if it comes to that."
• Your son (Rohit, 28 yrs) is insisting loudly: "Do everything, doctor! Put him on the ventilator now!"
• You are torn. You don't want to go against your son. You stay quiet initially
• If the doctor speaks to you privately or directly asks, "Mrs. Gupta, had your husband ever expressed any wishes about this?" - you will hesitantly share what he told you
• After sharing, you become emotional: "But doctor, that was before. He was healthy then. Maybe he has changed his mind? I don't know what to do. You tell me, doctor."
• You want the doctor to make the decision for you - push back gently if the doctor tries to hand the decision entirely back to the family

SCENARIO 3 - ISBAR Handover During Surge

🟦 CARD 3A - OUTGOING DUTY DOCTOR'S CARD

🟥 CARD 3B - INCOMING NIGHT DUTY DOCTOR'S CARD

• Has every patient been accounted for?
• Are there any critical patients requiring immediate action tonight?
• Are there any pending tasks that the outgoing doctor has left?
• Has the death certificate been completed for any patient who died today?
• Is there any medico-legal documentation outstanding?
• Are there any vulnerable patients (pregnant, elderly, DNR) with special instructions?
• Has the DNR status been communicated to nursing staff?
• Are any drug doses due in the next 2 hours?

SCENARIO 4 - Communicating with a Vaccine-Hesitant Patient

🟦 CARD 4A - DOCTOR'S CARD

• The vaccine being given is a licensed, WHO-approved vaccine (e.g., COVID-19 vaccine)
• Common misconceptions in the community include: "The vaccine contains a microchip," "It causes infertility," "Natural immunity is better," "The vaccine was made too quickly to be safe," "I am healthy so I don't need it"
• Your goal is NOT to force or pressure him - it is to address his concerns with evidence and respect his autonomy. Ultimately, vaccination is voluntary
• If he declines after proper counselling, document his informed refusal

• Open the conversation non-judgmentally - do not start by dismissing his concerns
• Use motivational interviewing: ask open questions, reflect, affirm, inform
• Address at least 2-3 of his specific concerns with factual, simple explanations
• Explain what to expect after vaccination (mild side effects = normal immune response)
• Respect his final decision
• Document the encounter: either vaccination consent or informed refusal

🟥 CARD 4B - PATIENT'S CARD

• You are educated (B.Ed. degree) and consider yourself a rational person
• You are part of a WhatsApp group of teachers where a lot of vaccine-related information is shared - some of it alarming
• You have come to the vaccination camp because your wife insisted and your school requires proof of vaccination for in-person work, but you are genuinely uncertain

1. First concern (raise this first): "Doctor, I read that this vaccine was developed in just 8-9 months. Normal vaccines take 10-15 years. How can it be safe? Were corners cut?"
2. Second concern (raise if first is addressed): "My neighbour's son took the vaccine and got fever for 3 days and body pain. It made him sick. What is the point of a vaccine that makes you sick?"
3. Third concern (if still not convinced): "Someone in my WhatsApp group shared a video saying the mRNA vaccine changes your DNA permanently. Is that true? I don't want my genes changed."
4. Fourth concern (if pressed): "I had COVID last year. Mild case. I recovered fully. Don't I already have natural immunity? Why do I need the vaccine on top of that?"

• If the doctor listens, uses your name, and explains things in plain language without condescension - you gradually become more receptive
• You don't need to be 100% convinced - a realistic outcome is: "Okay doctor, I will think about it. Maybe I will take it today. Can you be with me for 10 minutes after the injection just in case?"

• If the doctor talks down to you, uses jargon, dismisses WhatsApp as "nonsense," or pressures you - become more resistant: "See, this is exactly why people don't trust doctors. You are not listening to me."

OBSERVER / FACILITATOR REFERENCE

Print this for the student(s) observing each role play. They score in real-time.

Universal Communication Checklist (All 4 Scenarios)

Printing guide: Print each lettered card (1A, 1B, 2A, 2B, 3A, 3B, 4A, 4B) on a separate sheet. Laminate for reuse. Keep doctor cards (A) and patient/family cards (B) in separate colored envelopes to prevent accidental cross-reading before the session.

VIDEO SCRIPT TEMPLATE

"How to Run a Live Debrief After a Role Play"

Final Year MBBS | Pandemic Module + AETCOM | NMC CBME

PRODUCTION NOTES (For Video Team)

SEGMENT 0 - COLD OPEN

"What you are about to watch is a live debrief session following a medical role play. The role play has already happened. A student played a doctor breaking the news of a pandemic death to a grieving family. The debrief - what happens next - is where the real learning occurs. Watch how the facilitator runs it, step by step."

SEGMENT 1 - FACILITATOR SETUP (Pre-Debrief, 60 seconds)

🟡 PAUSE & REFLECT — Why does the facilitator ask observers to put their checklists down first? What is the risk if observers lead with scores immediately?

SEGMENT 2 - GATHER PHASE (3-4 minutes)

🟡 PAUSE & REFLECT — The facilitator has not corrected anything yet. Why? What is the purpose of letting the student voice discomfort before the analysis begins?

SEGMENT 3 - ANALYZE PHASE (8-10 minutes)

WHAT WENT WELL         WHAT TO WORK ON

SECTION 3A - WHAT WENT WELL (Always first)

🟡 PAUSE & REFLECT — The facilitator is asking observers and the actor before moving to critique. What is the psychological effect of building the "what went well" list first?

SECTION 3B - WHAT TO WORK ON (The teaching core)

DOCUMENTATION MUST INCLUDE:
1. WHAT was communicated (specific content)
2. TO WHOM (names, relationship)
3. Their RESPONSE / understanding
4. Any REFUSAL or CONCERNS raised + how addressed

🟡 PAUSE & REFLECT — Identify the three teaching points covered so far in the Analyze phase. Could you sequence them differently? Would the impact change?

SECTION 3C - PEER FEEDBACK FROM OBSERVERS

SEGMENT 4 - SUMMARIZE PHASE (3 minutes)

TODAY'S THREE TAKEAWAYS:

1. Presence > Accuracy
   (Put the paper down. Know the name before you enter the room.)

2. Compassionate boundary-holding
   (The rule does not change. Your humanity around the rule — you control that.)

3. Documentation = Your only witness
   (What · To whom · Their response · Refusal/concerns + resolution)

SEGMENT 5 - OUTRO / VOICE-OVER SUMMARY

"What you just watched was a 15-minute debrief built on three phases: Gather, Analyze, Summarize. The facilitator did not lecture. She asked questions. She named specific behaviors - not vague impressions. She let the student speak before correcting. She used the patient-actor's experience as data. And she ended with something every student wrote and kept."

"The debrief is not a review of what went wrong. It is the construction of what to do differently - built by the learner, anchored in a real experience, and carried forward into clinical practice."

DEBRIEF CHECKLIST FOR FACILITATORS

GATHER
□ De-roled both actors formally
□ Established psychological safety
□ Asked doctor: "How did it feel?" — before any analysis
□ Asked patient-actor: "What did you experience?" — before any analysis
□ Did NOT correct anything in this phase

ANALYZE
□ Started with "What went well" — always
□ Used advocacy-inquiry for each critique point
□ Used specific observed behaviors — not vague labels
□ Invited peer observer feedback — one item each
□ Covered documentation explicitly

SUMMARIZE
□ Students wrote their own takeaways — not dictated
□ Read 2-3 aloud without attribution
□ Named 3 carry-forward behaviors on the board
□ Bridged to next clinical opportunity
□ Closed with human acknowledgement between actors

TOTAL TIME TARGET: 12-18 minutes

"The role play creates the experience. The debrief creates the learning." — NMC AETCOM Framework, Communication Competencies Module

PRODUCTION APPENDIX

A. Shot List Summary

B. What the Facilitator Must NOT Do - (For Faculty Training Use)

C. Timing Guide

If a 60-minute session includes a role play (7 min) + a second run with role-rotation (7 min) + debrief (17 min) + documentation writing (5 min) + facilitator close (4 min) = 40 minutes — leaving 20 minutes for a second scenario or a structured Q&A.

D. Reference Framework Citations in This Script

• GAS Debriefing Model - Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simulation in Healthcare. 2007;2(2):115-125
• Advocacy-Inquiry Technique - Rudolph JW, et al. There's no such thing as "nonjudgmental" debriefing. Simulation in Healthcare. 2006;1(1):49-55
• SPIKES Protocol - Baile WF, et al. SPIKES - a six-step protocol for delivering bad news. The Oncologist. 2000;5(4):302-311
• PENDLETON'S Model - Pendleton D, et al. The Consultation: An Approach to Learning and Teaching. Oxford University Press, 1984
• NMC AETCOM Communication Module - Role Play and Feedback Framework, AETCOM Booklet, NMC India (available at nmc.org.in)