Emergency. 2018; 6 (1): e36 OR I G I N A L RE S E A RC H Awareness of Basic Life Support among Egyptian Medical Students; a Cross-Sectional Study Esraa Ghanem1,2, Muhammad Elgazar1, Khaled Oweda1, Hussein Tarek1, Fathy Assaf1, Mostafa Wanees Ahmed El-Husseny3, Ahmed Elgebaly1, Abdelrahman Ibrahim Abushouk2,4∗ 1. Faculty of Medicine Al-Azhar University, Cairo, Egypt. 2. Cross Sectional Research Group of Egypt, Cairo, Egypt. 3. Faculty of Medicine, Fayoum University, Fayoum, Egypt. 4. Faculty of Medicine, Ain Shams University, Cairo, Egypt. Received: Apri 2018; Accepted: June 2018; Published online: 16 June 2018 Abstract: Introduction: It is important for all medical and paramedical staff to be aware of basic life support (BLS) maneu- vers. In this study, we aimed to evaluate the level of BLS awareness among Egyptian medical students. Methods: The level of BLS knowledge was assessed using a validated questionnaire and the results were analyzed using an answer key, prepared from the Advanced Cardiac Life Support (ACLS) manual. We used the Student’s t-test to an- alyze the association between awareness level and year of study, previous BLS training and practical experience. Results: A total of 823 medical students with the mean age of 20.3 ± 2.7 years, from Al-Azhar medical schools completed the questionnaire (463 and 360 in academic and clinical years, respectively). About 72% and 84% of students failed to recognize the proper point of chest compression in adults and infants, respectively. Moreover, the majority (80%) did not know how to give rescue breathing in infants. Only 18% of students correctly identi- fied early signs of shock and only 22% knew how to help patients with myocardial infarction. Being in clinical years, previous BLS training or practical experience were significantly associated with higher BLS knowledge scores (p < 0.001). Conclusion: The level of BLS awareness among Egyptian medical students is generally poor. Introduction of regular BLS courses into the undergraduate curriculum is a must to increase the level of BLS knowledge among Egyptian future physicians. Keywords: Awareness; cardiopulmonary resuscitation; education, medical; students, medical © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: Ghanemi E, Elgazar M, Oweda Kh, Tarek H, Assaf F, Wanees Ahmed El-Husseny M, Elgebaly A, Ibrahim Abushouk A. Awareness of Basic Life Support among Egyptian Medical Students; a Cross-Sectional Study. Emergency. 2018; 6(1): e36. 1. Introduction C ardiac arrest is a life-threatening event that accounts for 15% of the global mortality and is more common in individuals with a pre-existing cardiovascular con- dition (1)(2). In Egypt, it is estimated that hypertension and coronary heart disease affect 25% and 8.5% of the popula- tion, respectively (3), increasing the liability to sudden car- diac arrest events. The emergency management of cardiac arrest involves a series of simple maneuvers, known as ba- ∗Corresponding Author: Abdelrahman Ibrahim Abushouk; Faculty of Medicine, Ain Shams University, 11566, Ramsis st, Abbasia, Cairo, Egypt. TEL: 0201014295781, FAX: 020132706152 Email: Abdelrah- man.Abushouk@med.asu.edu.eg sic life support (BLS) (4). These maneuvers include recog- nizing the signs of sudden cardiac arrest, heart attack, stroke and foreign-body airway obstruction, cardiopulmonary re- suscitation (CPR), and defibrillation with an automated ex- ternal defibrillator (AED) (5,6). The simple skills, a trained BLS provider should have, can reduce the high mortality rate associated with cardiac arrest in patients with cardiovascu- lar disease. Moreover, cardio-respiratory arrest can also be seen in neonates and infants (7), with slight differences in the BLS algorithm that healthcare providers should be aware of. Therefore, each individual in the community, specially the medical staff, should have adequate knowledge and train- ing in providing BLS maneuvers (5). Several studies have assessed the levels of BLS awareness among medical stu- dents in different countries (5âĂŞ8). However, similar data This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com E. Ghanem et al. 2 on Egyptian medical students are lacking. Therefore, we performed this cross-sectional study to assess BLS aware- ness among medical students in two large Egyptian medical schools. 2. Methods 2.1. Study design and setting We conducted a cross-sectional study at Al-Azhar University, Cairo, Egypt. We obtained verbal consent from all partici- pants after explaining the study objective and the voluntary nature of the questionnaire. The confidentiality of obtained data was maintained according to the Helsinki Declaration of bioethics (as revised in 2008).We followed the Strength- ening the Reporting of Observational Studies in Epidemiol- ogy (STROBE) statement guidelines during the preparation of this cross-sectional study (9). 2.2. Participants All officially-enrolled undergraduate medical students at Al- Azhar University (including two medical schools) were eligi- ble for participation. The educational model in most Egyp- tian medical schools is similar where students study basic medical (preclinical) sciences during the first three years and applied (clinical) sciences during the final three years. We used the convenience sampling method for enrolling partic- ipants, actively attending university courses. 2.3. Study questionnaire and data collection We used a validated, closed ended, self-administrated ques- tionnaire with 20 questions about BLS maneuvers (assess- ment of airway, breathing, circulation in unresponsive vic- tims, recognition of early signs of shock, CPR technique, and AED use). This questionnaire was developed by referring to previous studies (5–8). Later, we added a section about the demographic data of enrolled students to our survey and an- other question to determine whether students had attended BLS training courses before. A pilot study on 50 students was conducted to test the comprehensibility of the questions and time needed for completion. We used an online survey pro- gram (Google Documents) to enter the data. 2.4. Data Analysis For calculation of sample size, we used Raosoft software (Based on the number of students in both schools, a com- bined sample size of 682 students was sufficient to provide a power of 90% for this study). Questionnaire forms with more than two missing elements were removed from the analysis. Analysis of the results was performed, using SPSS (Statisti- cal Package for Social Sciences) software (version 20 for win- dows). Results were analyzed using an answer key, prepared from the Advanced Cardiac Life Support manual. Numerical Table 1: Baseline and demographic data of participating medical students Variable Total (n=823) Age (years) (mean ± SD) 20.3 ± 2.7 Sex Male 727 (88.3%) Female 96 (11.7%) Year of enrollment Academic 463 (56.3%) Clinical 360 (43.7%) Cumulative academic score Excellent 227 (27.6%) Very Good 314 (38.2%) Good 187 (22.7%) Pass/Poor 29 (3.50%) Residency area Rural 522 (63.4%) Urban 301 (36.6%) Data are presented as frequencies and percentages unless stated otherwise. Figure 1: Flow diagram of sampling and analysis processes. variables were reported as means and standard deviations, while categorical variables were reported as frequencies and percentages. The student’s t-test was used to analyze the as- sociation between awareness level and year of study, previ- ous BLS training or practical experience. 3. Results 3.1. Basic Data of Enrolled Students A total of 823 students completed the survey (Figure 1), in- cluding 727 males (88.3%) and 96 females (11.7%). Among participating students, 463 students (56.3%) were enrolled in the academic study years, while 360 students (43.7%) were This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2018; 6 (1): e36 in the clinical study years (mean age: 20.3 ± 2.7 years). Ta- ble 1 summarizes the baseline characteristics of participating medical students in this study. 3.2. Students’ knowledge about basic life support Among all included students, only 222 students (27%) reported previous attendance of BLS courses, while 282 (34.3%) stated that they had attended an external medi- cal/paramedical course before. The correct meaning of the abbreviation “BLS” was only identified by 364 (44.8%) stu- dents. Only 254 responders (30.9%) could select ‘look for safety’ when asked about the first thing to do when you find an unresponsive person in the middle of the road. More- over, only 78 students (9.5%) could identify “Activate EMS” as the immediate response after confirming the unresponsive- ness of that person. The detailed responses to BLS knowledge questions are illustrated in Table 2. 3.3. Association between baseline characteristics and overall score We detected a statistically significant association between sex and the overall score (p < 0.001), with females achieving significantly higher scores than males. No statistically sig- nificant association (p = 0.07) was found between the over- all score and place of residence (rural/urban). As expected, medical students in the later clinical years achieved signifi- cantly higher scores than those in the three academic years (p < 0.001). Moreover, a statistically significant association was found between the overall score and previous attendance of BLS courses (p < 0.001) or undergoing medical/paramedical training (p < 0.001). 4. Discussion Our study showed a significant lack of BLS knowledge among the enrolled participants. Although nearly 60% of the respon- ders reported previous attendance of BLS courses, more than 50% of them could not even identify what the abbreviation "BLS" stands for. Moreover, around 90% of them could not identify ’activate EMS’ as the first step in the chain of sur- vival, which is important to get advanced medical care in the exact time. What is more concerning is that two-thirds of the students did not recognize "look for safety" as the first thing to do upon finding an unresponsive patient, which could en- danger the lives of both the victim and the rescuer. Knowing the proper location, rate, and depth of compressions is also important (10). Chest compression at the proper site ensures adequate blood pumping to the circulation to maintain brain perfusion. However, more than 70% of our participants could not identify the correct site of chest compression in adults and 80% could not do the same in infants. Moreover, less than 15% could identify the right depth of chest compres- sion in adults, children, and neonates, which makes CPR use- less or even harmful. Less than 10% of our participants could identify the correct ratio of compression-ventilation in adults or neonates. In case of suspecting an airway obstruction, the first step to confirm that is by talking to the victim. More than 85% of the participants could not identify this step. More- over, only 25% of the students could identify the correct tech- nique of foreign body removal in a choking infant. In case of acute coronary syndrome and stroke, there is a limited period in which the early signs of vascular occlusion should be rec- ognized before the ischemic damage becomes irreversible. However, only 20% of enrolled students could identify those signs in both cases of stroke and acute coronary syndrome. Following cardiac arrest, time equals life. For every minute post-cardiac arrest with no resuscitation, there is a decrease in survival rate by 7 to 10% (11). A survival rate of 50 to 75% is possible if CPR and defibrillation are performed within 3 to 5 minutes of cardiac arrest (12,13). It is expected from the practicing physicians to have good BLS skills because they face cases of cardiac arrest daily in their hospitals (14). In case of out-of-hospital cardiac arrest, there is an essential role for the bystanders to provide the initial care, which itself may be enough for survival (15) or until experienced medical staff get in place. A major role of spreading the knowledge of BLS skills is on the medical students, especially in develop- ing communities (16). Similar studies have shown poor BLS knowledge levels in different countries (5–8), highlighting the importance of a global consensus among medical educators to enhance BLS training of undergraduate students. Accord- ing to a recent study in Scandinavia, following BLS training, there was an increased knowledge of BLS skills among partic- ipating students with reduced time needed to establish CPR in out-of-hospital cardiac arrest situations (8). 4.1. Strength points versus limitations of this study According to our knowledge, our study is the first to assess the knowledge about BLS in Egypt. Being a multicenter study, its results can be generalized to a wide population of Egyp- tian medical students. However, we did not assess BLS prac- tical skills among our respondents. This should be the fo- cus of future studies. Similar surveys should be conducted not only among the medical students, but also among the general population for the purpose of creating numerous BLS rapid responders in the community. Our results also highlight the need for regular reassessment and refreshing courses for those who already got involved in previous BLS courses. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com E. Ghanem et al. 4 Table 2: Detailed responses to BLS knowledge questions among participating medical students N Question Correct Answer Frequency (%) 1 What is the abbreviation of “BLS”? Basic Life Support 364 (44.2) 2 When you find someone unresponsive in the middle of the road, what will be your first response? (Note: You are alone there) Look for Safety 254 (30.9) 3 If you confirm somebody is not responding to you even after shaking and shouting at him, what will be your immediate action? Activate EMS 78 (9.5) 4 What is the location for chest compression? Mid Chest 228 (27.7) 5 What is the location for chest compression in infants? One finger breadth above the nipple line 129 (15.7) 6 If you do not want to give mouth-to-mouth CPR, the following can be done EXCEPT No CPR 139 (16.9) 7 How do you give rescue breathing in infants? Mouth-to-mouth and nose 162 (19.7) 8 Depth of compression in children during CPR 1 –1 1/2 inches 103 (12.5) 9 Depth of compression in adults during CPR One-half to one-third depth of chest 78 (9.5) 10 Depth of compression in neonates during CPR One-half to one-third depth of chest 110 (13.4) 11 Rate of chest compression in adults and children dur- ing CPR 100/min 72 (8.7) 12 Ratio of CPR, single rescuer in adults is 30:2 136 (16.5) 13 In a new born the chest compression and ventilation ratio is 3:1 87 (10.6) 14 What does abbreviation AED stands for? Automated External Defibrillator 63 (7.7) 15 What does abbreviation EMS stands for? Emergency Medical Service 178 (21.6) 16 If you and your friend are having food in a canteen and suddenly your friend starts expressing symptoms of choking, what will be your first response? Confirm foreign body aspiration by talking to him 115 (14) 17 You are witnessing an infant who suddenly started choking while he was playing with the toy, you have confirmed that he is unable to cry (or) cough, what will be your first response? Back blows and chest compression of five cycles each then open the mouth and remove foreign body only when it is seen 225 (27.3) 18 You are witnessing an adult unresponsive victim who has been submerged in fresh water and just removed from it. He has spontaneous breathing, but he is unre- sponsive. What is the first step? Keep him in recovery position 102 (12.4) 19 You noticed that your colleague has suddenly devel- oped slurring of speech and weakness of right upper limb. Which one of the following can be done? Possibly stroke, he may require thrombolysis and hence activate emergency medical services 151 (18.3) 20 A 50-year-old gentleman with retrosternal chest dis- comfort, profuse sweating and vomiting. What is next? Probably myocardial infarction, hence activates EMS, give an aspirin tablet and allow him to rest 180 (21.9) Abbreviations: AED: Automated External Defibrillator, BLS: Basic Life Support, CPR: Cardiopulmonary Resuscitation, EMS: Emergency Medical Service. 5. Conclusion Our study showed a poor level of knowledge about BLS skills among Egyptian medical students. Introduction of regular BLS courses into the undergraduate curriculum is a must to increase the level of knowledge about BLS among our future physicians and improve awareness of the general population of these life-saving skills. 6. Appendix 6.1. Acknowledgements None. 6.2. Author contribution All authors made substantial contributions, revised the manuscript, and approved the final version for publication. Ghanem E, Elgazar M, Oweda K: Conception and design of the study. Tarek H, Assaf F, Elgebaly A: Data collection and analysis. El-Husseny MWA and Abushouk AI: First draft writ- ing and preparing illustrations. 6.3. Funding sources None. 6.4. Conflict of interest None to Declare. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 5 Emergency. 2018; 6 (1): e36 References 1. Bogle BM, Ning H, Mehrotra S, Goldberger JJ, Lloyd- jones DM. Lifetime Risk for Sudden Cardiac Death in the Community. Journal of the American Heart Association. 2016;5(7):e002398. 2. Pundalika D, Narayan R, Biradar S V, Reddy MT, Bk S. As- sessment of knowledge and attitude about basic life sup- port among dental interns and postgraduate students in Bangalore city , India. World Journal of Emergency Medicine. 2015;6(2):118–22. 3. Kurdi MI. Coronary artery disease in Africa and the Middle East. Therapy and Clinical Risk Management. 2012;8:65–72. 4. Tipa RO, Bobirnac G. Importance of basic life support training for first and second year medical students - a personal statement-. 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