ACLS Update

Today I took my ACLS update and I did my PALS update about two weeks ago. I'm now sure that a person's success at ACLS and running through the scenarios is inversely proportional to a person's pay scale. In other words, the more your get paid, the worse you do at ACLS.

To illustrate my point:

My group today for recertifications consisted of an ER physician, multiple nurses, and 3 paramedics. The worst performer of the group was the ER physician--he overlooked the BLS survey (the look, listen, and feel), didn't know drug dosages, and had to refer multiple times to his pocket guide to double check the algorhythm.

The ICU, CCU, and ER nurses in my group performed slightly better. About half remembered the BLS survey, although some would skip steps (such as not checking a pulse and jumping from giving breaths to starting compressions). Most of the nurses had trouble identifying the heart rythms, which I guess is understandable. The majority of the nurses had a firm grasp of what drugs to give when, although they seemed a little iffy on dosages.

By far, the best performers at the skill stations were the paramedics. The medics were on top of the BLS survery, made smooth transitions from assessments to treatments, knew the heart ryhtms without questions, and knew the algorithms by heart.

Now, I'm not trying to say that medics know better than nurses and physicians, but I think that with the way the ACLS course is taught, it creates an environment for medics to do better. The course starts with the BLS assessment and CPR, followed by field interventions, and skills that are performed by medics on a very regular basis. Conversely, many of the nurses in my classes had no prior training in field assessment skills, or more technical skills such as intubation or needle decompression. Many of the nurses were unsure of their roles and stated multiple times, "well, the doctor normally would do that," or "I'd call for the doctor."

Doctors, on the other hand, aren't expected to perform CPR in a clinical setting, or be the ones to start the IVs or push the drugs. They often aren't expected to be the ones to perform the BLS assessment (as an example, one of the physicians in my class was an oral surgeon).

Medics practice these skills on a daily or weekly basis, incorporating the BLS survey, ALS skills and interventions, and transportation and turnover into all of their patient contacts. Nurses and doctors don't have the beginning-to-end exposure that medics in the field do and can therefore lack the same skill set. Many of the nurses in my class talked about how the patients they see on a daily basis already have an IV or airway established, how the diagnosis and treatment has already been determined, in other words, much of the guess work is already been done for them.

So the other medic students and I spent over three hours (or our six hour day) this morning going over the CPR video (a skill that we should already come to class proficient in). We then watched corny DVD videos of nurses, doctors, and EMTs perform the cardiac arrest algorithms (all of which were done with far too much urgency and energy to seem realistic or reassuring). After this we performed basic airway adjuncts like the OPA and non-rebreather masks (skills that we learned in EMT-Basic school and should be proficient in). We spent only 1 hour of our 6 hour day practicing the "mega-code" scenarios. So I have to wonder, where is the "Advanced" in Advanced Cardiac Life Support? My partners and I wanted only to do our scenario and take our test--get in and out in an hour. Really, the science and skills hadn't changed in 2 years. These are the 2005 guidelines, right?

Ideally, I'd love it if ACLS was taught in such a way that it focused on the skill level of the providers. ACLS for paramedics would focus more on the core cardiac arrest cases. ACLS for basic level providers would focus on core CPR skills and basic science. ACLS for nurses would focus on in-hospital interventions and working as part of a team with a doctor in the lead. ACLS for doctors would focus on the more tertiary aspects of cardiac arrest management, identifying and correcting causes of cardiac arrest that can't necessarily be identified or corrected in the field.

But the AHA has their way of doing things and who are we to questions, other than the providers that render their standards of care.