The stupidification of ACLS.

[OVeractiveBrain]

So, Im pretty sure the incidence of prehospital return of spontaneous circulation in a non-traumatic arrest is about 50%. How many of those end up going home is another story. Medical codes, particularly ones in dense metropolitan services where response times are short, and even more so in areas where bystander education and intervention is great (i.e. seattle) have a pretty good chance of resuscitation. Personally, I have worked 5 prehospital codes (2 BLS 3 ALS) and EVERY one has had a return of spontaneous circulation. Strictly anecdotal, and I am awesome, so maybe not representative of the EMS field (also more modest than most). But seriously, joking aside, prehospital management of a cardiac arrest mirrors hospital intervention and can be fairly successful.

If you think about it, the parallels are quite apparent. In the ER you have a documenting RN, a med RN, an intubating/code-running doc, a nurse/tech x2 for compressions and maybe an extra hand. In the field, the paramedic assumes the role of doc, another medic may have control of the meds (obtaining access and administration of meds), FD EMT/MRTs for compressions, and your BLS partner to bag after the tube is in. AZCEP is right, the management in both cases is quite similar. As for you, ERDoc, you can take your higher education and superior knowledge/skill/experience right out the door with you! TVP! HA! ILL TVP YOU!

In any case, it is true that the structure and rigor of ACLS isnt really there. That is why medics (at least I hope) go through the rigor they do in class. Personally, when I went into ACLS we had already covered mostly everything, to the point of absolute memorization, prior to the ACLS cert. ACLS for prehospital providers I feel is more along the lines of updating changes, refreshing knowledge, and generating a certification for what we do anyway. For others, such as nurses and physicians, is more along the lines of familiarizing these practicioners so they arent caught totally off guard when they are asked to use those skills. For Docs in the ER, it is not their ACLS certification, but rather their knowledge and experience beyond the cert, that allows them to control a code. The cert defines an obvious, known baseline; a minimum that all providers expect from those who have completed the course. Does the RN assisting the doctor need to know the difference between an SVT with aberrancy and Vtach to push the Amiodarone? No. But if the doctor calls from 450mg Amio, she can say, "isnt that too much?" If everyone on the code CAN differentiate, so much the better, but it is not necessary (too many chefs spoiling the meal kind of thing). Just because the certification isnt rigorous does not mean there is less emphasis on the field or the expectations of the providers is any less. We paramedics are expected to perform at a level higher than that of our certification. That is what excellence is all about. Knowing that we, as well as our fellow providers, at least meet the minimum standard and are made aware of the practice is useful in the field.

I also thin tnuiqs hit it on the head. In order to disseminate information to a vast number of people it is necessary to dumb down the information and make it easy to remember. For we paramedics, ACLS is our life-blood. Its 50% of what we do. Its pretty much all that matters from a medical standpoint. The monitor and our drug bag are designed for the interpretation and treatment of cardiac emergencies. But to another provider who has more concerns than just ABCs should be familiar with cardiac care, but also must save room for other information that pertains to them. So, our liscencing bodies decides the quality of knowledge while the AHA can educate and produce information quickly and easily to as many people as possible.

Overactive

[1EMT-P]

When I took my first ACLS class we were responsible for not only reading the book, but we were also responsible for knowing all of the ACLS medications, Ekgs and modalities and the rationale behind the various modalities & treatments. There was no such thing as a group code or open book test. You either knew the material or you didn't.

[AZCEP]

So, Im pretty sure the incidence of prehospital return of spontaneous circulation in a non-traumatic arrest is about 50%. How many of those end up going home is another story. Medical codes, particularly ones in dense metropolitan services where response times are short, and even more so in areas where bystander education and intervention is great (i.e. seattle) have a pretty good chance of resuscitation.

Where did you get your numbers from? Every resource I've ever seen has placed the resuscitation of cardiac arrest <10%. All of them included. Yes the patient that arrests in front of you with the defib pads attached will do significantly better, but does this happen very often. Seattle's numbers have been slipping over the years, by the way. Fewer and fewer citizens want to initiate bystander CPR, even there.

Personally, I have worked 5 prehospital codes (2 BLS 3 ALS) and EVERY one has had a return of spontaneous circulation. Strictly anecdotal, and I am awesome, so maybe not representative of the EMS field (also more modest than most). But seriously, joking aside, prehospital management of a cardiac arrest mirrors hospital intervention and can be fairly successful.

Yes they can be quite successful if the stars align correctly. Of the 5 successes that you've experienced, how many of them had other factors that led to their resuscitation? Short down time to CPR? Short time to first shock? Not to deflate your "modesty" but there were other factors at work beside your presence.

If you think about it, the parallels are quite apparent. In the ER you have a documenting RN, a med RN, an intubating/code-running doc, a nurse/tech x2 for compressions and maybe an extra hand. In the field, the paramedic assumes the role of doc, another medic may have control of the meds (obtaining access and administration of meds), FD EMT/MRTs for compressions, and your BLS partner to bag after the tube is in. AZCEP is right, the management in both cases is quite similar.

My goodness, you have a lot of people on a scene. While it is ideal to have four people in a transporting unit to work an arrest, this does not happen outside of the city limits very often. This might account for the sucess you described. Let me assure you that assigning a role to each person is good, but it is not without problems of it's own.

In any case, it is true that the structure and rigor of ACLS isnt really there. That is why medics (at least I hope) go through the rigor they do in class. Personally, when I went into ACLS we had already covered mostly everything, to the point of absolute memorization, prior to the ACLS cert. ACLS for prehospital providers I feel is more along the lines of updating changes, refreshing knowledge, and generating a certification for what we do anyway. For others, such as nurses and physicians, is more along the lines of familiarizing these practicioners so they arent caught totally off guard when they are asked to use those skills. For Docs in the ER, it is not their ACLS certification, but rather their knowledge and experience beyond the cert, that allows them to control a code. The cert defines an obvious, known baseline; a minimum that all providers expect from those who have completed the course. Does the RN assisting the doctor need to know the difference between an SVT with aberrancy and Vtach to push the Amiodarone? No. But if the doctor calls from 450mg Amio, she can say, "isnt that too much?" If everyone on the code CAN differentiate, so much the better, but it is not necessary (too many chefs spoiling the meal kind of thing). Just because the certification isnt rigorous does not mean there is less emphasis on the field or the expectations of the providers is any less.

Unfortunately, the system you describe is inaccurate. The ACLS program is not designed to test anyone on anything more than rote knowledge. Even this takes a backseat to reference material and "expert consultation". The information that is gained from the standard ACLS class is no longer about testing the students to find out if they understand the concepts that are presented. It has become an issue of giving recognition to someone that can attend a class, nothing more.

The providers may well have the same expectations, but the emphasis has been taken away from ensuring their knowledge to flooding the market with providers that truly do not understand what they are trying to do.

We paramedics are expected to perform at a level higher than that of our certification. That is what excellence is all about. Knowing that we, as well as our fellow providers, at least meet the minimum standard and are made aware of the practice is useful in the field.

What level are you eluding to here? We are not expected to perform beyond our education/certification. ACLS/PALS/CPR are not certifying entities, and haven't been for almost 10 years. You receive a course completion document, that is all. ACLS is part and parcel of the national curriculum for paramedics, therefore it is part of our scope of practice. The problem is the minimum is not being met with this program any longer.

I also thin tnuiqs hit it on the head. In order to disseminate information to a vast number of people it is necessary to dumb down the information and make it easy to remember. For we paramedics, ACLS is our life-blood. Its 50% of what we do. Its pretty much all that matters from a medical standpoint. The monitor and our drug bag are designed for the interpretation and treatment of cardiac emergencies. But to another provider who has more concerns than just ABCs should be familiar with cardiac care, but also must save room for other information that pertains to them. So, our liscencing bodies decides the quality of knowledge while the AHA can educate and produce information quickly and easily to as many people as possible.

How many arrests happen in your system? Maybe this is why you've had the success you mentioned. ACLS is not 50% of what a paramedic does. It would be a reach to think that ACLS makes up 20% of what paramedics are responsible for. The majority of treatment options may well be better than this percentage, but this does not mean that paramedics are dealing with these types of emergencies on that many occasions.

The problem that all of the alphabet soup classes have run into is quite apparent. They all want the healthcare community to view them as valid. To do this more providers need to carry the credential that they put out. If the requirements are too rigorous, not enough will pay for the privilege of attending the classes. So to make the content more friendly, they make it easier to pass, or turn it into a "monkey see, monkey do" curriculum. Watch this video, push on this manequin, get your card.

This is not a benefit to anyone that requires someone to administer the treatments that should have been discussed, and practiced in the classroom.

[ERDoc]

Tranvenous pacing is not indicated in the current guidelines for the management of cardiac arrest. Bradycardias, sure, but not pulseless arrest.

As an aside, doesn't it take a significant amount of time to get the TVP in place?

ACLS is more than just cardiac arrests. I agree that in the standard case, TVP is not indicated but you always have those cases that don't fit the textbook mold. I once had this guy with a pacemaker that decided it didn't want to work properly. He was 100% dependent and every couple of minutes it would stop working, for a few minutes. So, in essence this guy was in asystole and therefore in cardiac arrest. Best thing to do is drop a TVP in. We did it and the guy was fine after that. I'm not saying you are wrong, I'm just nit-picking for the fun of it . A TVP really doesn't take that long to put in. It takes about 5 min tops to get the cordis catheter in and then another 5 to get the pacer in the right spot. To be honest, cardiologists are not as good at them as ER docs are. We put in way more cordis catheters than they do so we get more practice. That being said, could I successfully put in a balloon pump? Not likely.

[ERDoc]

As for you, ERDoc, you can take your higher education and superior knowledge/skill/experience right out the door with you! TVP! HA! ILL TVP YOU!

Overactive

BOW BEFORE MY SUPERIORITY!!!! FOR I AM THE ERDOC!!!! :twisted:

[Ridryder 911]

Nice to see there is still ER Doc's that can place TVP's in. It has been years since I have seen one placed in the ER. I believe it has became a lost art and procedure that needs to be re-enforced.

R/r 911

[ERDoc]

Nice to see there is still ER Doc's that can place TVP's in. It has been years since I have seen one placed in the ER. I believe it has became a lost art and procedure that needs to be re-enforced.

R/r 911

I think it is a procedure that is making a comeback. I am not far out of residency and we were taught how to do them. I did a few during residency, but have not had the chance to do any since. I don't know what the reluctance would be to do one.

[Thunderchild145]

Unfortunately, the system you describe is inaccurate. The ACLS program is not designed to test anyone on anything more than rote knowledge. Even this takes a backseat to reference material and "expert consultation". The information that is gained from the standard ACLS class is no longer about testing the students to find out if they understand the concepts that are presented. It has become an issue of giving recognition to someone that can attend a class, nothing more.

The providers may well have the same expectations, but the emphasis has been taken away from ensuring their knowledge to flooding the market with providers that truly do not understand what they are trying to do.

My question is that if the ACLS certified professionals aren't "experts" then who should we ask in the eventuality of needing "expert consultation"?

[AZCEP]

ACLS is not a certification. It hasn't been for roughly 10 years. Those that have completed the class receive a "course completion" document, nothing more. This does not indicate, in any way, they are "experts".

The "expert consultation" recommendation was added to prevent providers that don't know what they are doing from making a bad decision. It does not indicate that the provider is knowledgeable in the management of the situation.

[emtpstar]

Oh Yes!!! the good ole days when you were allowed to humiliate and treat people with disdain and disrepect. I have been an ACLS instructor for 17 years and I for one am glad they finally realized that treating people like they were in marine boot camp is outdated and not effective. What good does it do to make the course so intimidating and difficult that the majority of people are too "scared' to take the course. Sure, a select few who felt superior to everyone because they could memorize more information that everyone else could brag about how they survived. If you want to make the course difficult, then develop your own course but the American Heart Association has finally figured out that most adult learners do retain information when all they want to do is "pass" so they can keep their jobs. You want it tougher, great, make it tougher but don't blame the AHA just because they want to make this more accessible for everyone and not just the EMT profession. Not sure why we think it is a badge of honor to treat each other with disrespect and disdain. You want to feel good about survival, join the Marines and be a combat medic.